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Child's Name:*

Date of Birth*

What are your top concerns or questions about your child’s movement, coordination, or behavior?

What strengths or activities does your child enjoy most?

Anything else you feel is important to share?

Signing Parent / Guardian Name*

Signing Parent / Guardian Email Address*

Parent/Guardian Consent*

I give permission for my child to participate in the Reflex Integration Screening at Downtown Jewish Preschool (DJP).

I understand that this screening is observational and educational. It is not a medical evaluation or diagnostic assessment, but a tool to help guide a holistic approach to supporting my child’s development.

Note: After submitting this questionnaire, you will be redirected to a signature page to confirm authorization.

Billing Address

Street Address City State ZIP Code

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Credit Card

Cardholder Name

Card Details

Screening Fee

Price:

Total

Company

This field is for validation purposes and should be left unchanged.

Child's Name:*

Date of Birth*

What are your top concerns or questions about your child’s movement, coordination, or behavior?

What strengths or activities does your child enjoy most?

Anything else you feel is important to share?

Signing Parent / Guardian Name*

Signing Parent / Guardian Email Address*

Parent/Guardian Consent*

I give permission for my child to participate in the Reflex Integration Screening at Downtown Jewish Preschool (DJP).

Note: After submitting this questionnaire, you will be redirected to a signature page to confirm authorization.

Billing Address

Street Address City State ZIP Code

This page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes.

Credit Card

Cardholder Name

Card Details

Screening Fee

Price:

Total

Reflex Integration Screening Parent Questionnaire

Note: After submitting this questionnaire, you will be redirected to a signature page to confirm authorization.

Reflex Integration Screening Parent Questionnaire

Note: After submitting this questionnaire, you will be redirected to a signature page to confirm authorization.