Screening Information
Please fill out the following to begin the registration process.
Child's Full Name *
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's Current Grade Level *
Child's Current School *
Parents Name *
Address *
Email *
Phone number
Does your child have difficulty asking and/or answering questions? (with peers or adults) *
Does your child have difficulty taking turns with others? (during an activity and/or verbally in conversation) *
Does your child have difficulty making or keeping friends? *
Does your child prefer to play alone? *
Does your child "get stuck" on one topic or type of toy? *
Has your child received speech therapy or group services? *
Does your child have a medical diagnosis? *
Tell us about your concerns or anything else we should know about your child.
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