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.

School Schedule Form

Email *

Name of your school

School Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please provide the main C&B contact name

First Name

Last Name

Please provide the main C&B contact phone number

(###)

###

####

Please provide the main C&B contact e-mail

What school year you are currently scheduling for

2023-2024 (for 2024-2025 school year)

2024-2025 (for 2025-2026 school year)

Your preferred month/s for assessment dates

Select the following schedules your students adhere to

MWF

T and Th

M-F

Other

If selected "Other" please fill out below

Provide estimate number of students being assessed. If you have multiple schedules (see above), please indicate how many students for each type of schedule

What hours are we able to screen at school. Please specify students' nap time (start to finish) if applicable.

Approximately how many screeners is your space able to accomodate?

Who will pay for the screening? *

School

Parents

What is the school's Wifi Name and Password

Will you need us to assess any students in grades 2nd through 8th? *

Yes

Is this assessment mandatory for current students? *

Is this assessment mandatory for enrolling students or newly enrolled students? *

Thank you for filling out the online form. Someone will be in contact shortly.

Parent Schedule Form

Parent/Primary Contact Name *

First Name

Last Name

Primary Contact Phone Number *

(###)

###

####

Primary Contact Email *

Child's Name *

First Name

Last Name

Child's Date of Birth *

YYYY

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? *

Where would you like the results sent? *

School Contact Name and Email (If Applicable)

Thank you for filling out the online form. Someone will be in contact shortly.

1020 Calle Recodo
San Clemente, CA 92673

949-326-4917

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Chancy & BruceSchedule Form

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