Early Childhood Virtual Screening Interest Form

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Thank you for your interest in a virtual developmental screening. Please note that this option is only available upon request for families with an immunocompromised health status or other special circumstances related to their health.

Take a moment to complete this form. A member of office staff will reach out to you to go over the next steps.

Parent/guardian legal name (first and last): *

Child's legal name (first and last): *

Child's date of birth (mm/dd/yyyy): *

YYYY

Does your family have an immunocompromised health status? *

Yes

Does your family have a special medical diagnosis, medical only IEP, or special circumstance that would prevent an in-person screening? If so, please briefly explain. *

Parent/guardian phone number: *

Parent/guardian email address: *

Is there anything else you would like to mention or have questions about?

Submit

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