Screening Consent Form | barnetttherapy

Speech & Language Screening

Consent to Screen

By completing this form you are giving permission for Barnett Therapy Services to conduct a speech and language screening with your child.

The screening will be conducted at the discretion of Barnett Therapy Services. Completing this form does not guarantee that a screening will be conducted.

I give permission for Barnett Therapy Services to conduct a speech and language screening with my child. I understand that this is just a screening, not a full evaluation. Results will be given to me in written form and if there are concerns, my options will be discussed with me.

Parent's Name

Phone

Child's name

Date of Birth required

Gender

Please indicate any specific concerns you have:

School & Teacher

Parent's Signature

When you send this form, your child will be place on my Screening List. Please print a copy of this form and attach the payment of $20. Hand it in to your child's teacher or the director. They will hold on to it until I schedule the screening :)

Great! You are on my waiting list. Print your form, attach the $20 and give it to your child's teacher or the director! If I need to schedule the screening with you, I'll let you know. But most likely, I'll coordinate with the school :)Feel free to reach out if you need me! BarnettTherapy@icloud.com