FREE Developmental Screening Consent Form
Fill out this form to request that PlayRx pediatric therapists conduct a free developmental screening of your child at your child's daycare/center! Screening results will be returned to you via a secure BloomText chat directly from the company. Make sure your child is receiving all the support and resources they need to maximize growth and development!
Child's First Name
Child's Last Name
Child's Date of Birth
Parent/Guardian Full Name
Child's location/center
Child's classroom/teacher
Please list any concerns you may have and your reasons for requesting the developmental screen. This will allow our screeners to focus their screening on skills of concern. Thank you!
Check this box if you have any sensory concerns.
Check this box if you would like to bypass the screening process and take steps to move forward with formal evaluations.
*Cell Phone Contact Number
Email
I agree to receive my child's screening paperwork through a secure BloomText chat
Parent name:
Your Signature: By signing, you agree to a developmental screening for your child and to receive the results of screening via secure BloomText chat
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