Speech Services at Stavness Early Learning

Do you have a student at Stavness Early Learning, Calimesa with speech/language concerns? If you are interested in an informal speech/language screening to determine if your child would benefit from a formal evaluation, complete the form below or contact me at (909)767-6467.

*Only available for enrolled students

STAVNESS EARLY LEARNING
SPEECH-LANGUAGE SCREENING
REQUEST FORM

* Indicates required field

My child is currently enrolled at Stavness Early Learning, Calimesa *

Yes No (complete the form on our contact tab)

Child's Name *

First

Last

Legal Guardian Name *

First

Last

The person completing this form is the child's legal guardian *

Yes No (please contact the child's legal guardian to complete this form)

Playing Our Part Speech Therapy, P.C. has permission to contact me regarding scheduling the screening and the outcomes of the screening using my phone number and email listed here: Email *

Phone *

I understand that I can request a hard copy of the screening form via call/text (909)767-6467 or email ([email protected]) if I do not choose to complete this form online *

I understand

I understand the screening will occur during school hours at Stavness Early Learning, will last approximately 20 minutes, and involves informal measures. The screening will be conducted by Jennifer Lozano, M.S. CCC-SLP. *

I understand

I, the legal guardian named above, give Playing Our Part Speech Therapy, P.C. permission to complete the screening on my child whose name is listed on this form. I also give permission for my child's screening results to be shared with Stavness Early Learning staff and the person whose contact information appears above. By checking this box, I understand that I am electronically signing for consent *

I consent

*An evaluation may be pursed through your local school district or your medical insurance plan. If you would like to discuss private-pay options for evaluation and/or therapy, which can take place at Stavness Early Learning, please contact me. A screening helps determine if an evaluation is recommended.

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Our Hours
Tuesday: 9:00am - 5:30pm
Thursday: 9:00am - 5:30pm
Friday: 9:00am - 4:30pm
Available on limited basis: Monday, Wednesday, and Saturday
Closed: Sunday

Phone: (909) POP N HOP | (909)767-6467
12189 7th Street Suite 3, Yucaipa, CA 92399

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