Screening Permission Form

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I understand that the screening will last approximately 30 minutes and involves engaging in fine motor and gross motor activities that are age appropriate.

The screening will be conducted by Dru Harwood, MS, OTR/L.

Following the screening, you will receive a summary of the child's results as well as recommendations regarding whether further evaluation is warranted.

You have permission to contact me regarding the outcomes using my contact information listed here: Admin@playconnectpeds.com

Your name *

Phone number *

E-mail *

Your child's name *

Your child's birthdate *

What daycare/school does your child attend? Has the child being screened ever received therapy services? If yes, please describe below. If not please answer N/A: *

Please share any concerns about the child being screened:
*

Check here to give Play Connections Pediatrics, LLC permission to complete the screening and share the results with the person whose contact information appears above.

Yes! I give permission to screen my child for any OT needs.

I would like more information first.

Required

Any questions or comments?

Submit

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