Request edit access
Screening Appointment Request
To schedule an appointment please fill out the information requested below. Please note, dates are tentative and based on community need. A staff member will contact you when a screening has been scheduled in your area.
Screening location *
What time would you like your appointment to take place?
Your answer
Child First Name *
Child First Name
Your answer
Child Last Name *
Child Last Name
Your answer
Date of Birth *
Your answer
Child Gender *
Parent First Name *
Your answer
Parent Last Name *
Your answer
Home Phone *
Your answer
Street Address *
Your answer
City and Zip Code *
Your answer
Email Address
Your answer
Preferred Method of Contact *
Next
Never submit passwords through Google Forms.
This form was created inside of High Desert ESD. Report Abuse - Terms of Service - Additional Terms