Screening Authorization

This form is HIPPA compliant and encrypted so your information will be kept secure!

the parent/guardian of

Child's DOB

(the “Child”), hereby give a representative of The Loop Speech, Language, and Learning, LLC permission to evaluate the Child during a 15-minute speech/language/learning/occupational therapy screening. I understand that this screening is only a brief observation and although it is possible that speech, language, learning, or OT difficulties may be recognized during such an observation, a longer and more thorough evaluation is necessary to definitively diagnose such problems. Therefore, I agree that I will not hold The Loop Speech, Language, and Learning, LLC liable in the event a speech, language, learning, or OT difficulty is not recognized during this screening. I understand that recommendations will be made after this screening and the results of the screening will be discussed with me.

Signature of Parent/Guardian

Date

Parent Email Address

I acknowledge that there is a $25 charge for screeners

Area(s) of Concern for Screener

Speech/Articulation

Errors with how certain sounds are pronounced

Language/ Fluency

How your child understands or uses language; stuttering

Occupational Therapy

Sensory Processing Difficulties, Emotional Control and Self-Regulatory Skills, Fine Motor Skills, Gross Motor Skills, Visual Perceptual Skills, Executive Functioning Skills, Self-Care Skills

Learning

Reading, Spelling, Math, Executive Function Skills

Area(s) of Concern Explained:

School

Grade

Teacher/Classroom

Teacher Email

Your information will be encrypted.

Screening Authorization

This form is HIPPA compliant and encrypted so your information will be kept secure!

This form is HIPPA compliant and encrypted so your information will be kept secure!

The Loop SLL