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Preschool Screening 2022-2023
This information is being submitted for screening purposes only. It is not considered an evaluation nor a request for evaluation. If after the screening team reviews the information and recommends an evaluation, the team will be in contact with you.
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* Indicates required question
Email
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Your email
Parent(s) name
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Your answer
Parents email address
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Your answer
Mailing address
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Your answer
Child's name
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Your answer
Child's Date of Birth
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MM
/
DD
/
YYYY
What areas of your child's development have you most concerned? Check all that apply.
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Speech (clarity of speech/articulation)
Language (understanding language/using words, phrases or sentences to communicate
Socialization (interacting with peers or adults)
Fine Motor development
Gross Motor Development
Cognition (concept knowledge, memory, problem solving)
Behavior (attention, restlessness, difficulty with coping)
Required
Please provide details regarding the above checked concerns
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Your answer
What strategies/ideas have you tried to help with these concerns?
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Your answer
Has your child ever received Early Intervention or received private therapy? If so, please provide some details.
Your answer
Is your child currently enrolled in a preschool program?
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No
Yes, part-time
Yes, full-time
Other
What other opportunities does your child have to interact with age-matched peers? (playgroups, Sunday-School, Little Gym, sports, extended family, etc.)
Your answer
Please provide any other information you feel would be helpful in getting to know your child and understand your concerns.
Your answer
Send me a copy of my responses.
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