Parental Consent to Screen/Assess

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 his/her speech-language, and or occupational therapy skills.
  • I understand that assessment results may be shared with preschool staff and/or Alberta Education as it pertains to my child’s programming.
  • If for some reason, my child does not attend this designated preschool site, I will be required to reimburse the cost of the assessment at the time the assessment is completed.
  • I authorize Pathways to apply for funding with Alberta Education for my child, if needed.

  • Please check all that apply:

  • I would like my child to be seen for a screening by a Speech Language PathologistI would like my child to be seen for a screening by an Occupational Therapist
  • My child has been seen by a Speech Language Pathologist before
  • My child has been seen by an Occupational Therapist before

  • MaleFemale
  • MonTuesWedThursFri
  • MorningsAfternoonsFull Days
  • By checking this box you are digitally signing this form
  • 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.

    Under the Freedom of Information and Protection of Privacy Act personal information is for use within Pathways confidential files only.

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