Schedule Appointment

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We know you are busy!
Let us schedule your initial placement screening for your child. Its simple- just fill out the form below, answer a few questions, and send it in. Once we receive your request, we will email or call you with an appointment day/time!

I would like to make an appointment for a Social Butterflies Club Placement Screening.

The best day for me/my child is *

Please select a day and time that you prefer. We will email you back with an appointment!

The best time is *

Child Information

My Child's Name *

My child's communication method is *

Verbal Sign Language Communication Device Picture Communication Non-Verbal

Please pick the one that your child uses the most.

Does your child have difficulty taking turns with others? (During an activity and/or verbally) *

yes no

Does your child walk around the perimeter of the playground or prefer to play in the sand box? *

yes no

Does your child have a speech-language delay or a fine/gross motor delay? *

yes no

My Child's Date of Birth MM/DD/YYYY *

Does your child have difficulty asking and/or answering questions? (with peers or adults) *

yes no

Does your child have difficulty making friends because he/she prefers to play alone or does not like to share? *

yes no

Does your child “get stuck” on one topic or type of toy? *

yes no

Does your child have difficulty in the classroom setting and following the rules of the class? (Sitting for circle time or structured tasks,standing in line, following directions, etc.) *

yes no

Tell us about your concerns (optional) *

Parent information

Parent Name *

First

Last

Phone number where you can be reached to schedule an appointment *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Submit