Keri Skipper, MCD CCC-SLP

Phone: 864-406-6769

Child’s Date of Birth: ____________________________________________________________________

Parent’s Name: ________________________________________________________________________

Parent’s Phone: ________________________________________________________________________

Insurance carrier: ______________________________________________________________________

Days/times child is present at daycare: _____________________________________________________

ABOUT SCREENINGS: Your child’s free developmental screening will measure skills in the areas of

speech/language, gross and fine motor, self-help, social/emotional development, and cognition. A

screening does not measure mental age or IQ, nor will it diagnose a child. Results of the screening will

indicate whether or not, on this particular day, your child can perform skills at his/her current age level.

Please keep in mind that all children develop at a different rate. Please list any concerns you may have

personnel. Records will not be released to other sources without my written permission. I understand

that by signing this permission my child will be screened in the areas described above, but no future

screenings or formal evaluation will occur without my written permission. I give permission for my

child’s screening results to be forwarded to:

None: __________________ Physician: ____________________ BabyNet: ________________________

Signature: ______________________________________________________ Date: _________________