Chancy & Bruce
Parent Schedule Form

Please complete this form with the most accurate information to aid the scheduling process. After we receive your request, someone will get in touch with you shortly to schedule your screening window dates.

The cost is $79 for a 20-40 Minute one-on one screening
completed with in-depth results.

Parent School Form

Parent/Primary Contact Information

Primary Contact Phone Number

(###)

###

####

Primary Contact Email

Child Information

Child's Name

First Name

Last Name

Child's Date of Birth

What grade is your child currently in?

What grade will your child be entering for the following year?

What is the primary language spoken at home?

Does your child have an IEP or 504 plan?

Results Destination

Where would you like the results sent?

School Contact Information

chool Contact Name and Email (if applicable):

School Name

Optional Academic Component

Are you interested in adding the academic component aligned to the California State Standards for an additional $10 per student?

Chancy & Bruce
Parent Schedule Form

Get Started

New School

Chancy & BruceParent Schedule Form

Get Started

New School

Chancy & Bruce
Parent Schedule Form