Consent for Evaluation/Assessment v 3.4.13

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Family
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Address
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City, State, Zip
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Child’s Name
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DOB
Enter Local tiny-k Program specific info here
Reason for Notice
The Infant-Toddler Program is required to obtain your permission before conducting evaluation and assessment activities. Further, it is required that you give informed, written consent for these activities through your signature below. The purpose of evaluation and assessment is to determine your child’s initial eligibility for early intervention services in Kansas, as well as your child’s developmental strengths and needs. This is your statement of consent. / Consent" means that: (1) You have been fully informed of all information about the activity(ies) for which consent is sought in your native language (unless clearly not feasible to do so) or other mode of communication; (2) that you understand and agree in writing to the carrying out of the activity(ies) for which consent is sought; (3) the consent describes the activity(ies); and (4) the granting of your consent is voluntary and may be revoked in writing at any time.

Action Proposed

A multidisciplinary team, comprised of you, a person(s)from at least 2 different disciplines and your family service coordinator,will conduct an evaluation and assessment. The evaluation is a comprehensive view of how your child is doing in the developmental areas of cognition, gross motor, fine motor, communication, social-emotional, adaptive, health including vision, and hearing. The evaluation results will be used to determine if your child is eligible for early intervention services. Assessment refers to the initial and on-going assessment of the child and family and involves identifying unique strengths and needs based upon daily routines and activities. The results of the evaluation and assessment are kept in your child's early intervention record. This information will remain confidential.

Description

How the evaluation/assessment is performed will vary based on the needs of you and your child. It will include review of available medical/developmental records, parent interview, child observation, and administration of formal and informal evaluation and assessment tools. Evaluation team members will talk with you about these methods.

Timelines

The multidisciplinary team evaluation, assessment and development of an Individualized Family Service Plan (IFSP) must be completed within 45 calendar days from the date your child was referred to the early intervention program. If your family needs additional time beyond the 45 days, it is important that you tell your Service Coordinator. The IFSP is a written plan developed in partnership with your family and professionals to meet the ongoing needs of your child and family. It can be changed at any time. The IFSP is written only if your child is eligible for service. Whether or not your child is eligible for early intervention, you will receive Prior Written Notice regarding eligibility.

Parent(s) Guardian Acknowledgment and Statement of Consent

I acknowledge being provided a copy of the Child and Family Rights and the Kansas ITS Complaints Process – Kansas Infant Toddler Services. This information has been explained to me and I understand it. As discussed in this information, Ihave the right to contact the Kansas Department of Health and Environment at 785.296.6135 or 1.800.332.6262 and make an informal complaint, formal written complaint, request mediation and/or an impartial due process hearing should I disagree with the above proposed or refused action(s). For more information, I may also consult the Kansas Infant Toddler Services website at

I do I do not: give my informed consent for my child to participate in the Evaluation/Assessment as described above.

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Parent/Guardian Signature Date

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Parent/Guardian Signature Date

Note: Parents are to receive a copy of this form