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 *
Child's Name
Child's Date of Birth
Child's Date of Birth
Daycare Contact Name
Daycare Contact Name
Parent/Caregiver
Parent/Caregiver
Parent's Contact Phone Number
Parent's Contact Phone Number
Address
Address
Physician's Name
Physician's Name
Physician Phone
Physician Phone