Healthcare CPSE Evaluation Consent Form

Healthcare CPSE Evaluation Consent Form

Child/Patient Name:   CPSE ID:

Date of Birth:   Gender:

Parent / Legal Guardian Information

Phone:   Email:

Emergency Contact

Insurance / Billing Information

Policy Number:   Group Number:

Medical History

Evaluation Requested (check all that apply)

Developmental Speech-Language Occupational Therapy Physical Therapy

Psychological / Educational Behavioral Assessment Hearing Vision

Medical Evaluation Adaptive Behavior Assistive Technology

Consent and Authorization

I, the undersigned parent or legal guardian, authorize the Committee on Preschool Special Education (CPSE) designated evaluators and their agents to perform the evaluation services checked above. I understand that these evaluations may include direct assessment, observation, standardized testing, medical screening, and parent/guardian interview as appropriate to determine eligibility for preschool special education services.

I understand the nature and purpose of the evaluations and that results will be documented in records maintained by the CPSE. I acknowledge that evaluation activities may involve routine screening procedures and noninvasive techniques. I understand that benefits include identification of areas of need and development of recommendations for early intervention or preschool special education services. I understand that there are no substantial risks associated with the listed evaluations, and that any concerns about specific procedures may be discussed with providers in advance.

I authorize the release of relevant educational and medical records to CPSE evaluators and permit CPSE to share evaluation results, reports, and recommendations with authorized school district personnel and service providers involved in planning or providing early intervention or preschool special education. I also authorize CPSE to request records from prior providers as needed to complete a comprehensive evaluation.

To facilitate continuity of care, I authorize the following provider(s) or organization(s) to release records and reports to CPSE:

I understand that I may revoke this consent at any time by submitting a written statement to the CPSE contact indicated on evaluation paperwork, except to the extent that action has already been taken in reliance on this consent. Revocation will not affect disclosures already made in reliance on this authorization.

This authorization is valid until:   If left blank, this authorization will remain in effect for one year from the date of signature unless revoked earlier in writing.

Privacy and Records

I acknowledge that information collected in the evaluation process is protected under applicable privacy laws. I understand that CPSE will use and disclose information only as permitted by law for evaluation, eligibility determination, planning, and delivery of services. I acknowledge receipt of the CPSE privacy practices and understand my rights regarding inspection, amendment, and an accounting of disclosures as provided by law.

I acknowledge receipt of the CPSE privacy practices and notice of privacy rights.   Initials:

Additional Authorizations

I authorize audio and/or video recording of assessment activities when required for clinical documentation or team review.

I authorize photographs of the child for clinical records and treatment planning only.

I understand that refusing to sign this consent may delay or prevent the completion of the CPSE evaluation and subsequent eligibility determinations. I have had the opportunity to ask questions and have received answers in language I understand.

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