Schedule a Free Screening

(An $80 value)

Schedule a free screening to gain a better understanding of your child’s developmental level. You will spend some time with one of our highly-trained therapists and have your questions and concerns addressed. At the end of the 30 minute screening you will walk away with tailored recommendations to support your child’s continued development at home. Additionally, if your child requires a higher level of support, our therapists can help you make a more informed decision about evaluations or other referrals.

Pre-Screening Information

Completing this form will alert our staff that you would like to schedule a free screening. One of our office staff will be in contact to set up a time. Free screenings can be scheduled between the hours of 7:30am - 3:00pm, based on therapist availability. Completing this form will help our therapists prepare for the screening.

Child's Name*
First
*
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Child's preferred pronouns*
How did you hear about us?*
Type of Insurance:*
Emerge Pediatric Therapy is an in-network provider for all Tricare insurance plans, Health Choice, and NC Medicaid. We will bill these plans directly and collect any co-payments and deductibles as necessary. We are out-of-network for private commercial insurance plans. Please visit our FAQ page on our website to learn more: https://www.emergepediatrictherapy.com/about-us/faq/
Caregiver Name (First, Last)*
Email*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
If referred by a friend or family member, who referred you for a free screening?
What are your concerns for your child (at home, school, etc.)?*
What have professionals told you about your child?*
Is your child currently receiving any additional services or have they received them in the past? If so, please explain.*
Are there specific days and times that you are available to schedule the screening? If so please list below.