Has your child's teacher presented any concerns regarding her speech and/or language skills? * *
If you answered YES to the previous question, please further explain
Your answer
Does your child wear glasses? (If yes, please make sure they bring their glasses to school on the day(s) of the screening) *
Does your child have a history of ear infections? *
If you answered YES to the previous question, please list the date the most recent ear infection
Your answer
Have Pressure Equalization tubes been placed? *
If you answered YES to the previous question, please list the date the most recent PE tubes were placed
Your answer
Does your child receive any of the following? (check all that apply) *
Required
If your child is currently enrolled in speech, language, physical, and/or occupational therapy, please briefly explain what goals they are currently addressing in therapy.
Your answer
Is there a second language spoken in the home? *
If you answered YES to the previous question, please list the languages spoken in the home along with the child's primary language.
Your answer
Do you have concerns in any of the following areas: (check all that apply) *
Required
Please add any additional concerns
Your answer
Guardian's name who completed this form (By signing this form you are giving permission for NOSHC to screen your child) *
Your answer
Telephone number *
Your answer
Does NOSHC have permission to contact you through email? *
Payment instructions: 1. go to www.noshc.org 2. click on the blue payment button 3. Click on patient payment 4. screening fee is $30 5. under account number please type "McGehee screening" 6. I have made my payment for the screening through the www.noshc.org website *