Preschool Program Notification and Parental Release of Confidential

Information Form

To the Exceptional Children Preschool Program

Directions: To be completed by the appropriate preschool program representative and sent to the appropriate Exceptional Children Program contact. Upon receipt, the school system will contact the family to set up a follow-up meeting.

Child Name: / Date of Birth: / Gender: M F
Home Address Street: / City: / State: Zip:
Parent/Guardian:
______
Email: / [Address if different than above]
Street:
______
City: ______State:_____
Zip: ______/ Primary Language: ______
o  Interpreter needed due to English as a second language.
Home Phone: ( ) / Work Phone: ( ) / Cell Phone: ( )
Primary Contact Name: / Address: / Office Phone:
Office Fax:
Suspected delay in (check all that apply):
o  Motor skills
o  Cognitive skills
o  Social-Emotional skills
o  Communication skills
o  Behavioral skills
o  Speech-Language skills / Explain any interventions that have been tried (What did you do, how long did you try it, were any interventions successful?). Please attach documentation of interventions.
Specific records to be released to and/or received from this office (Please check):
o  Vision screening/evaluation results
o  Hearing screening/evaluation results
o  Social Emotional/Behavioral Health screening results
o  Developmental screen results (please attach)
¨  Dial-3/Dial-4
¨  Brigance
¨  PEDS
¨  ASQ
¨  None Available
¨  Any other appropriate information (specify here) / Purpose of the disclosure:
Notification for preschool Exceptional Children Program services
Educational/Instructional planning
Party to whom the disclosure will be made:
Name of school system in which the child resides: ______
State/Federal Pre-K program in which the child attends: ______

I give informed parental consent to disclose the confidential records listed above for the purpose(s) listed above, and to the part listed above:

Parent/Guardian Signature:______Date: ______Unless otherwise revoked, this authorization expires one year from the date of signature.