Speech/Language Preschool Screening Sign-up
*Your email is required only so we can contact you directly with any questions or concerns about your child.  No one outside of our office will have access to your email address.*
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Email *
Child's Name
Child's Date of Birth *
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My child attends preschool at *
My child attends school on the following days (Please check all that apply) *
Required
My child's teacher is *
Please describe any concerns you have with your child's speech, language, or fluency development: *
Person completing this form *
Relationship to child *
Consent
I understand that Speech/Language and Hearing screenings will be
completed by licensed speech-language pathologists from Vulcan Speech
Group. I understand that these screenings are not intended to diagnose
developmental delays or disorders but that they will help identify children
who could benefit from a formal evaluation. The results will be provided to
parents via a handout provided at the end of each screening.

I agree to pay the fee of $15 and I consent to have my child screened by Speech-Language Pathologists from Vulcan Speech Group at his/her preschool.  I have sent a Venmo payment to @VulcanSpeech or included a check made payable to Vulcan Speech Group.
By completing and submitting this form, I agree to use this as my digital signature providing consent for Vulcan Speech Group to screen my child and that I will provide the payment listed below to Vulcan Speech Group. *
Signed on this date *
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I have paid my child's $15 fee by *
I sent payment via venmo to @vulcanspeech.  
My venmo handle is
My check number is
(check made out to Vulcan Speech Group)
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