Student Evaluation Consent Form

STUDENT EVALUATION CONSENT FORM

Student Information

Parent / Guardian (or Adult Student) Information

Evaluation Requested / Purpose

I authorize the school district and/or contracted providers to conduct the following evaluations, assessments, and observations for the purpose of determining eligibility for services, educational planning, or treatment recommendations. Select all that apply:

Psychological assessment

Educational achievement / academic assessment

Speech and language evaluation

Occupational therapy evaluation

Medical or health screening

Other:

Scope and Procedures

The evaluation may include review of education and health records, standardized and informal testing, rating scales, observation in classroom or other settings, interviews with school staff and family, and consultation with outside professionals as necessary. Results will be used to inform educational decisions and may be shared with other professionals involved in the student's care as authorized below.

Release and Exchange of Records

I authorize the release and exchange of relevant records and information for the purpose of conducting the evaluation and coordinating educational services. Records to be released may include disciplinary records, attendance, academic records, healthcare/medical reports, prior evaluations, and teacher observations.

School records (attendance, grades, discipline)

Teacher reports and classroom observations

Prior evaluations and assessment reports

Medical or health records

Third-Party Evaluators / Providers

Consent and Authorizations

By signing below, I authorize the persons and entities named in this document to conduct the assessments described and to exchange records and information as necessary for the evaluation. I understand that:

• Information shared under this consent will be treated as confidential and disclosed only as permitted by law and as necessary to provide educational services.
• This authorization does not authorize the release of information beyond what is reasonably necessary for the evaluation unless I provide additional written consent.
• I may revoke this consent in writing at any time, except to the extent that action has already been taken in reliance on it; revocation will not affect information released prior to revocation.
• This consent will expire on the date specified below or one year from the date of signature if no expiration date is provided.

I understand that recordings (audio or video) may be used for assessment purposes only if I provide explicit consent below.

I consent to audio/video recording as part of the evaluation

Fees and Payment Responsibility

Fees for evaluations may apply depending on the provider. Please indicate payment responsibility:

School district / school will cover evaluation costs

Parent / guardian will be responsible for fees

Use health insurance (parent to provide billing information)

Acknowledgment of Rights

I acknowledge that I have the right to: receive a copy of this authorization; refuse or revoke authorization as described above; request restrictions on disclosures; and receive a copy of evaluation results. I further acknowledge that I have been provided an opportunity to ask questions and that my signature is voluntary.

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