Parental Consent to
Screening/Assessment Form

Your agreement of this screening and/or assessment is acknowledged by signing this parental consent form. Your signature indicates:

  • I consent to the participation of my child in a screening and/or assessment of their speech-language (ex: speech sounds, expressive language, etc.) and/or occupational therapy (ex: fine motor, sensory, etc.) skills.
  • I understand that assessment results may be shared with preschool staff and Pathways working partners as it pertains to my child’s programming.

If your child has been seen by other professionals, please provide the following information:

Personal Information

School Information

Name of Preschool/Childcare Facility - Next Year (if known)

Parent/Guardian Information

Alternate Contact for Parent/Guardian (if different from above)

If your child requires further involvement by a Pathways therapist, you will be notified regarding the next steps in the process.

You and your child’s participation in this project are voluntary.

Pathways works with Lead Foundation (ECS Operator) to provide a comprehensive learning team which includes a Certified Teacher, and if necessary any or all of the following: Speech-Language Pathologist, Occupational Therapist, Physical Therapist, Psychologist. Pathways therapists collaborate with the coordinating teachers at Lead Foundation to develop a program focused specifically on the individual needs of each child. I consent for Pathways to share information related to my child with Lead Foundation.