Westside Regional Center
Parents’ Consent for Assessment
Child___________________________________________Birth Date________________________UCI #______________
Primary Language at Home_________________________Agency___________________________Date______________
Consent for Assessment
Dear Parent or Guardian;
An individual evaluation to determine whether your child needs to begin or continue receiving early intervention
services from agencies participating in the Early Start Program is needed. The assessment will help to identify your
child’s strengths and areas of need. The assessment may include: 1) observation of your child at home or other
appropriate settings; 2) an interview with you; 3) review of medical or other reports you agreed to share; and 4)
evaluation using a Bayley IV and/or DAYC-2.
The assessment may be conducted in any or all of the following areas:
☐ Cognitive development
☐ Physical development, including a recent vision, hearing, and health status
☐ Communication development (expressive and receptive language)
☐ Social/Emotional development
☐ Adaptive development
☐ Family Needs Assessment: The Individual Family Service Plan (IFSP) is required, with the concurrence of the family, to
include a statement of the family’s concerns, priorities and resources related to enhancing the development of the child.
Assessment May be Completed by:
☐
☐ Speech and Language Specialist
☐ Teacher for the Visually Impaired
☐
☐
☐ Hearing Impaired Specialist
☐ Nurse
☐
☐
☐ Occupational Therapist
☐ Orientation/Mobility Instructor
☐
Early Intervention Specialist
☐
Other (specify)_________________________________________________________________________
☐
I consent to an evaluation/assessment of my child for purposes of determining eligibility and/or determining early
intervention needs.
☐ I
consent to a Family Needs Assessment. This information will be included in the IFSP to help identify family
priorities, needs, and resources related to my child.
I understand that the results will be kept confidential and that I will be invited to attend the IFSP meeting to discuss the
assessment results. It is also my understanding that no services will result without my written permission.
S
ignature of Parent/Guardian: _______________________________________________ Date: ___________________
IFSP Team Member __
__________________________________________________ Position ______________________
Agency ______________________________________________________________ Phone number _________________
Address__________________________________________________________City ____________________State______
Should you have questions regarding this assessment, do not hesitate to call the above named person.
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