Screening Your Child for Therapy Services

Milestone Therapy Services can provide screening to determine whether your child qualifies for therapy services.
Group screenings may be coordinated at area daycares. Contact us for more information about group screenings.

Child's Name

First Name

Last Name

Child's Date of Birth

YYYY

Medicaid Number

Daycare Contact Name

First Name

Last Name

Daycare Contact Email

Parent/Caregiver

First Name

Last Name

Parent's Contact Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physician's Name

First Name

Last Name

Physician Phone

(###)

###

####

Physician Email

Please indicate any areas of special interest or concern.