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 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, Pathways working partners 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 or any services that have been provided by Pathways and it’s working partners.

I authorize Pathways Pediatrics to apply for funding with Alberta Education for my child, should services be recommended.

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

    • Comments:

      Personal Information:

    • School Information
      Current Year

    • MonTuesWedThursFri
    • MorningsAfternoonsFull Days
    • Next Year (if known)

    • MonTuesWedThursFri
    • MorningsAfternoonsFull Days

    • Parent/Guardian Information

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

    • 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.

      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.

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