Good to Grow- Screening Consent Form 

We are offering your child a free developmental screening!

If you are interested in a virtual screener, AFTER completing this form, please schedule your screener by Clicking Here

If you are inter Participation is voluntary and will not be performed without your consent. 

The screening results are not a diagnosis, but recommendation that your child may benefit from services offered within the community. If a more in depth evaluation or other services are recommended, you will be contacted by one of our team members and provided additional information.

The developmental screening may include: cognitive development, speech and language development, behavioral or social/emotional development, fine and gross motor development, sensory processing and self-help skills. The screening is designed to help identify those children who may need additional services, increase access to services, and provide additional information to families regarding child development. If any developmental delays in these areas are suspected, a member of our team will contact you to discuss recommendations.

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E-Mail-Adresse *
Date: *
Please enter today's date
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Child-  First and Last Name *
Please enter your child's full name below
Child- Date of Birth *
Please enter your child's full name below
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We must have your written permission to proceed with the screening process. All results and recommendations will be discussed in detail with you. 

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Pflichtfrage
Do you have concerns about your child’s development?
 *
If you answered YES above, what areas are you concerned about (check all that apply)? *
Pflichtfrage
Parent/Guardian-  First and Last Name *
Please enter your full name below
Street Address, State, Zip Code *
Phone Number (555-555-5555) *
Email Address (abc@domain.com) *
Electronic Signature (Type Full Name)
By typing your name below, you consent to all Stride Therapy and Wellness to use your entry as your electronic signature. 
E-Signature  *
E-Signature Date *
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E-Signature Time *
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Sie erhalten unter der von Ihnen angegebenen E-Mail-Adresse eine Kopie Ihrer Antworten.
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