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CONSENT FOR SCREENING, EVALUATION, AND ASSESSMENT

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SCDHHS/IDEA PART C/19MAR2021/ALL PREVIOUS VERSIONS ARE VOID
CONSENT FOR SCREENING, EVALUATION & ASSESSMENT FORM
CONSENT FOR SCREENING,
EVALUATION, AND ASSESSMENT
SECTION 1: REASON FOR CONSENT
Orientation and Intake
Initial IFSP
6-Month Review
Annual Review
Other
Activity(ies) for which consent is needed:
Screening
Eligibility Evaluation
Family Assessment
Child Assessment
Service Evaluation
S
ECTION
2:
C
HILD
,
P
ARENT
,
AND
S
ERVICE
C
OORDINATION
I
NFORMATION
Child’s First and Last Name:
Date of Birth:
BRIDGES ID #:
Parent Name:
Name: Intake Coordinator Service Coordinator
Information gathered will be kept in your child’s IDEA/Part C record and will remain confidential. Your child’s
records may be shared among any of the IDEA/Part C State Agencies, which include the South Carolina
Department of Health and Human Services and to the extent they may serve your child, its providers.
SECTION 3: PARENT CONSENTS
‘Consent’ means your Intake Coordinator, Service Coordinator and others working with your child must have your permission, in
writing, before any action occurs that affects your child. We want to be sure you completely understand the action, so you can let us
know if it will be okay with you. Your Intake Coordinator or Service Coordinator will tell you what will happen if you give your
permission and if you do not.
Check one
Yes
Activity
I/We have been informed of the screening process and the right to request an
eligibility evaluation any time during the screening.
I/We give permission for screening of my child’s development (including health,
hearing, and vision) to determine the need for an eligibility evaluation.
I/We give permission for screening of my child’s risk for Autism Spectrum Disorder
(N/A if child is younger than 15 months of age) to determine the need for an eligibility
evaluation.
I/We give permission for an evaluation of my child’s eligibility for IDEA/Part C.
If my child is determined eligible for IDEA/Part C, I/We give consent to participate in
an assessment of my family’s resources, priorities, and concerns for development of the
Individualized Family Service Plan (IFSP).
If my child is determined eligible for IDEA/Part C, I/We give permission for my child
to receive an assessment of her/his unique strengths and needs for development of the
IFSP.
SECTION 4: CONFIRMATION OF CONSENT AND SIGNATURE(S)
☐ I give my informed consent for IDEA/Part C to carry out the activities checked ‘Yes’ above.
Signature of Parent
Date
Signature of Parent
Date
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CONSENT FOR SCREENING, EVALUATION, AND ASSESSMENT

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Completed 9 March 2022

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