Pediatric Therapy Solutions

Self Screener Form

To help us determine whether or not your child may need intervention, please select your child's age and answer the following questions below.

Please Select Your Child's Age *

0-3 Months

3-6 Months

6-9 Months

9-12 Months

Your Name *

Your Last Name *

Email Address *

Phone Number *

Please answer all questions and enter in your information before submitting.