Between the Lines
Event Address: 909 W. Roseburg Ave. Modesto, Ca
Contact us at (209) 408-0957 or
Between the Lines is a program designed to provide intense language support to young children, ages 2 to 4 years old. It is a play-based program, offering low-ratio facilitation and training. Parents drop off their child for a 90 minute class. We provide a snack during the class.
Parent's Full Name
Parent's Phone Number
Child's First Name
Child's Age (years, months)
Which areas of your child's development are you most concerned about?
Communication/Language (i.e., saying words or phrases, understanding basic instructions)
Social Skills and Interaction with peers
Self-Help Skills (i.e., dressing, washing hands, feeding self, toileting)
Gross Motor Skills (i.e., walking, jumping, kicking a ball)
Fine Motor Skills (i.e., holding a crayon, picking up Cheerios)
Cognitive Skills (i.e., problem solving, matching, completing puzzles, playing with toys appropriately)
Behavior (i.e., following mastered instructions, tantrums, hitting, playing harmoniously with others)
How would you describe your child's play skills?
My child plays with cars, baby dolls, action figures, blocks in the appropriate way.
My child plays with a few toys appropriately, or shows little interest in most toys.
My child does unusual things with toys, inspects them rather than plays with them, drops them straight down repeatedly, throws them or overall does not know how to play with toys.
My child roams around, and needs constant help to stay entertained; he/she does not truly play with toys for at least 2 minutes.
My child is too young, he/she holds toys and chews on them (infants, young toddlers).
How would you describe your child's communication skills?
My child uses many words to ask for what he/she wants.
My child uses language to label familiar items, 10-20 words.
My child is using some words, he/she mostly communicates with gestures and/or grunting/whining.
My child points and asks for some items.
My child is not yet using true words, he/she is less than 12 months old.
I feel my child is delayed in this area and I would like a speech therapy consultation for my child.
Service History (describe in "Other")
My child has never received services for developmental delay.
My child has received services for developmental delay.
My child is currently receiving services for developmental delay.
My child is being assessed or will be assessed for developmental delay.
What days will you attend?
Wednesday 10-11:00am Language Lab
I understand that this program is a voluntary, privately-secured supplemental program and is not apart of my child's IFSP or IEP. I am fully responsible for the financial tuition of this program.
I am not sure and would like more explanation.
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