SCREENING CONSENT

We're Ready To Help

We are here to help and support your child's needs. Please complete the form below and we will contact you for next steps.

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Patient Needs: * Required

Fine Motor Difficulties

Motor Planning Difficulties

Self-Care Skills

Sensory Processing

Visual Processing

Cognitive Delays

Social Interaction Skills

Play Skills

Movement, Strength, Balance Delays

Learning Challenges

Other (specify below)

I'm Not Sure

Does your child attend preschool or daycare?

What class is your child in?

What days does your child attend school?

Monday

Tuesday

Wednesday

Thursday

Friday

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Your Signature

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Mailing Address

Pediatric Therapy of Colorado

PO Box 745113

Arvada, CO 80006-6113

720-664-6688 | 720-664-4675 (fax)

M-F 9am-5pm

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