Pediatric Therapy Screening Tool for Speech-Language and Occupational Therapy

Teletherapy Screening

Ready to find out if our teletherapy services are right for your child? Complete this brief screening questionnaire to get started. Our team of therapists will carefully review your answers and provide a personalized recommendation on whether telehealth therapy is a good next step.

Request for Teletherapy Screening:

URL
This field is for validation purposes and should be left unchanged.
Patient Name*
DOB*
Parent/Guardian Name*
Phone*
Email Address*
Section A: Basic Eligibility
Primary language(s) spoken at home:*
- English
- Spanish
- Other
Other language(s) spoken at home (Use comma to separate)
Is the child able to follow simple verbal directions?*
- Yes
- With visual support
- No
Is the child comfortable separating from a caregiver for brief periods?
- Yes
- Occasionally
- No
Does the child have a diagnosis that may affect attention or behavior (e.g., ADHD, ASD)?
- Yes
- No
Primary communication modality:
- Verbal
- Sign
- AAC device
- Gestures
- Other
Other primary communication modality comma separated
Section B: Attention, Participation, and Behavior
Can the child remain seated and attend to a screen for at least 10 minutes with breaks?
- Yes
- With support
- No
Is the child able to interact with an adult through a screen (e.g., Zoom, Google Meet)?
- Yes
- Occasionally
- No
Does the child require frequent redirection to attend to tasks?
- No
- Moderate support
- High support
Does the child exhibit aggressive, destructive, or elopement behaviors?
- No
- Occasionally
- Frequently
Section C: Caregiver Availability and Support
Will a caregiver be present during teletherapy sessions?
- Always
- Sometimes
- Rarely
Can a caregiver assist with technology and behavioral support during sessions if needed?
- Yes
- With guidance
- No
Are household distractions (e.g., TV, siblings) manageable during session times?
- Yes
- Occasionally interfere
- Frequently interfere
Section D: Technology Access
Devices available for therapy:
- Desktop
- Laptop
- Tablet/iPad
- Smartphone
- None
Internet reliability:
- Stable Wi-Fi
- Occasional issues
- Unreliable/No internet
Has the caregiver used Zoom/teletherapy software before?
- Yes
- With help
- No
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