Joint Screening | Referral | Consent Form
Date of Referral: / //
CPS Home School:
Address of School:
Early Head Start/Head Start Disability Coordinator:
Phone: / () - / Email:
Parent/Guardian: / Relationship to Child:
Primary Home Language: / Child’s Primary Language:
Address:
City: / State: / Zip:
Primary Phone #: / Cell Phone #:
Child’s Name: / Date of Birth: / // / Gender: M F
Birthplace:
Address: (If different from above)
U.S. Dept. of Education: New Race and Ethnicity Categories Part A asks about one’s ethnicity and Part B asks about one’s race. Ethnicity describes culture and language, while race describes the geographical origin of one’s ancestors. Both questions must be answered.
Part A. Is the child Hispanic/Latino? yes no
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Part B. What is the child’s race? Choose one or more.
American Indian or Alaskan Native Asian Black or African American
Native Hawaiian or Other Pacific Islander White
REASON FOR REFERRAL: (attach documentation)
Screening Results Teacher Observation Parent Request Transitioning from Early Intervention
AREAS OF CONCERN:
Cognitive/Educational Health Hearing Motor
Social/Emotional Communication Vision Other:
Comments:
Child’s Name:
Joint Screening | Referral | Consent Form /
ENROLLMENT DOCUMENTATION: (attach documents)
Proof of Age Proof of Address
AGENCY MAKING REFERRAL:
DFSS Child Care DFSS Early Head Start/Head Start Ounce Head Start
Agency/Site Name:
Agency/Site Address:
Agency Phone #: / () - / Fax: / () -
Agency Contact Person:
Signature of Contact Person:
PARENTAL CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION AND ENROLLMENT:
I have been fully informed about my child’s screening results and understand that CPS will review all available information and make a determination about which areas of concern require an evaluation of my child. I understand that before the evaluation can begin I must provide consent on a separate form and that my signature below does not grant this consent to evaluate my child. I also understand that my input during this determination is valuable and that if I disagree with the determination, I have the right to withhold my consent. I am authorizing CPS to enroll my child as a non-attending student for purposes of this evaluation process. I agree that CPS can share all information and findings about my child with the agency mentioned above.
This release of information is valid for one year form the date of the signature below.
Parent Name:
Parent Signature: / Date:
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