Schedule Your Screening
Parent's Name*
Email*
Phone*
Child's Name*
Child's Date of Birth *
Was your child born premature (before 37 weeks)? (if so, how many week)
Has your child previously receive therapy?*
Yes, at Pediatric Interactions
Yes, with another private or Early Intervention provider
Yes, at school
No
What are your preferred times of day to schedule the appointment? *
Questions/Comments:
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