A2 Therapy Works, LLC conducts free speech & language therapy and occupational therapy screenings at your child’s school. These screenings will be performed by certified and licensed speech-language pathologists and occupational therapists.

Please fill out the information below to opt in for the screening on Tuesday, October 22.

Child's name *

First Name

Last Name

Child's birthdate *

Child's age *

Guardian's name *

First Name

Last Name

Phone

(###)

###

####

Email *

Insurance provider

Child's classroom *

Days of attendance *

All 5 days

Monday

Tuesday

Wednesday

Thursday

Friday

Drop-off & pick-up time *

Example: 7:30am, 5:30pm

What are you interested in? *

Speech & language screener

Occupational therapy screener

Both

Do you ever feel like you are the only adult who can understand your child? *

Yes

Is your child speaking in single word phrases, or using the same phrases all the time? *

Yes

Does your child struggle with following simple directions? *

Yes

Does your child struggle with pretend play, attention, or interacting with other children? *

Yes

Does your child seem like they are always on the go and seeking constant movement? *

Yes

Does your child have difficulty copying pictures of shapes or letters? *

Yes

Is your child always bumping into or tripping over objects in their environment? *

Yes

Is your child a picky eater or do they have difficulty chewing/swallowing certain foods? *

Yes

Concerns

Consent for screening: By digitally signing below, you acknowledge and give consent to A2 Therapy Works to complete a speech-language and/or occupational therapy screening with your child. *

Consent for communication: By digitally signing below, you acknowledge and give consent to A2 Therapy Works to discuss your child and screening results with staff and teachers verbally, via phone, or via email. *

Today's date *

YYYY

Thank you!

If you or your child’s teacher answered yes to numbers 1-4, your child may benefit from a speech & language screening. If you and your child’s teacher answered yes to numbers 5-8, your child may benefit from an occupational therapy screening. Preschoolers and kindergarteners with delays are at a greater risk for learning disabilities, reading & writing difficulty, and overall academic problems. Early detection and intervention offer the most promising chances for improvement.

If you are interested in having your child complete a free screening, please fill out the information below. After the screening, you will be notified of the results in a sealed envelope. If the screening indicates that your child does not demonstrate any areas of concern or presents with error patterns that are developmentally appropriate, no further action will be required at this time. If your child does demonstrate areas of concern based on their age, you will be informed of the areas of difficulty identified and given information about potential next steps.

If you have any questions, please don’t hesitate to reach out to us via email or via phone 734-369-6002

Sincerely,

The A2 Therapy Works Team