Request edit access
Screening Appointment Request
To schedule an appointment please fill out the information requested below. We will confirm your appointment via your preferred method of contact.

If your desired screening date is unavailable, we may have reached capacity for that screening. Please call our office at 541-383-6357 to confirm.

Screening Date *
All dates are Friday unless otherwise noted
Desired Appointment Start Time *
Please choose your desired appointment start time. Screening takes 1-2 hours (2 or more children may take longer)
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 *
Never submit passwords through Google Forms.
This form was created inside of High Desert ESD. Report Abuse - Terms of Service - Additional Terms