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Screening Permission Form
Kim Martin, MS, CCC-SLP, owner and speech therapist of Words of Joy Therapy, is offering free articulation and preschool language screenings to students at participating locations. Please fill out this permission form if you wish to have your child screened free of charge. Upon completion of the screening, you will be presented with the results via email, phone call, or a note sent home. If your child does not pass the screening, you will be offered a free consultation where we can discuss speech evaluation/therapy options within the community (insurance,  private pay, school-based, etc.) as well as speech intervention support group options. 

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What is your child's name? *
What is your child's date of birth? *
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What school does your child attend? *
What days does your child attend school? *
Required
What time do you typically drop off and pick up your child? If in co-op, what time frame between 8-12:15 is ideal to screen your child? Also, what is his or her morning class schedule at co-op? *
Has your child ever received speech therapy services? If so, may I view prior therapy documentation such as evaluations, treatment plans, IEPs, etc? *
Please check the following concerns *
Required
Please share any additional concerns and teacher concerns
What are your child's favorite toys, books, shows, movies,  and/or songs?
 *
What the name of your child's teacher? *
Can I talk to your child's teacher about classroom performance,  concerns, and screening results?
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Can I provide intervention ideas to your child's teacher to help support speech and language growth? *
Caregiver's Name
Caregiver's Email 
Caregiver's Phone Number

Can I contact you via email and/or phone number regarding results of the screen?
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 By typing/signing my name below, I give permission for my child to be screened for Speech/Language Deficits.   *
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