Fillable CONSENT FOR WRCS INTAKE & ASSESSMENT DEPARTMENT TO (Westside Regional Center)

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CONSENT FOR WRCS INTAKE & ASSESSMENT DEPARTMENT TO (Westside Regional Center)

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Committed To Providing Support And Services To People With Developmental Disabilities
5901 Green Valley Circle, Suite 320, Culver City, CA 90230-6953
(310)258-4000 FAX: (310)649-1024 www.westsiderc.org
CONSENT FOR WRC’S INTAKE & ASSESSMENT DEPARTMENT
TO OBSERVE OR DISCUSS SCHOOL PROGRESS
Date:
(School or School District)
Re:
DOB:
The school your son/daughter attends is required by law to obtain a signed parental consent in order
to allow any person, including Westside Regional Center staff, to observe or discuss school progress. If
you would like WRC staff to continue having contact with the school, please sign the consent below and
return this form to your Service Coordinator:
WRC Contract Psychologist Name
Intake Counselor Name
I authorize the_______________________ School District personnel to discuss the school progress of
my son/daughter with Westside Regional Center psychologist.
Westside Regional Center staff may observe my son/daughter at school. (*For WRC
Diagnostic / Eligibility purposes)
I give permission for the school to release the following information to Westside
Regional Center: [Check box below]
Speech/Hearing Evaluation
Medical Evaluation
Education &/or Diagnostic Evaluation
OT, PT
Other (Specify)
*extended timed observation for Diagnostic / Eligibility purpose
(no longer than 1 hour)
Signature/Firma
Consumer, Parent, Guardian/Conservator
Relationship/Relación
Date/Fecha
Cc case record
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CONSENT FOR WRCS INTAKE & ASSESSMENT DEPARTMENT TO (Westside Regional Center)

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Completed 7 February 2021

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