Consent Form: Screening Assessment and/or Therapy Sessions

Child's Full Name*

Parent / Guardian's Name*

I, as the legal guardian/parent agree to allow the child to receive services through MaxECS. By signing this form, you are providing consent and agreement of:

The MaxECS certificated teacher and the MaxECS contracted Therapist(s) observing the child and conducting an initial screen and/or assessment of their skills and abilities within the classroom
Please Note: The MaxECS contracted Therapist(s) will contact you to discuss the results before moving ahead with therapy.

If there are needs and I as guardian/parent decide to agree to the funded program, I consent/agree to:

The MaxECS contracted Therapist(s) will provide input towards the child's IPP (Individualized Program Plan). The MaxECS contracted Therapist(s) will provide treatment and consultation thereafter.
The Therapist(s) corresponding via emails, face to face, telephone to communicate with the child’s teacher and/or classroom educational assistant, or other team members and allied professionals about the child’s programming.
I understand that the school will share assessments from other disciplines, and will share the child’s IPP with the Therapist(s), and I understand that formal reports from previous years can be shared in order to develop an integrated and coordinated program.
Photos and videos of the child performing therapy activities may be taken for your interest and to record their progress.
Please Note: If you do not wish the child to be photographed or videotaped, please advise of this immediately and before programming begins.

Parent / Guardian Signature:*

Child's Gender*

Male

Female

*Gender as per birth certificate

Child's Date of Birth*

Current Education Status*

Kindergarten

Preschool

This field is hidden when viewing the form

Age As Of August 31*

Basic Information

Parent / Guardian #1*

Parent / Guardian #2

Mailing Address*

Phone #1*

Phone #2

Preferred Email*

Daycare / Preschool / Kindergarten child currently attends*

Address

Choose Days Child Attends School

Monday

Tuesday

Wednesday

Thursday

Friday

Start Time*

End Time*

Daycare / Preschool / Kindergarten the child will be attending for 2026/2027*

Choose Days Child Will Be Attending School

Monday

Tuesday

Wednesday

Thursday

Friday

Start Time*

End Time*

Plans for 2027/2028*

Do you have a concern with the child's primary language?*

Yes

Languages spoken at home and percentage of time spoken:*

If more than 1 language, what do you consider the child’s primary language?*

If more than 1 language, how much English exposure has the child had?

(i.e., at home, in the community, through daycare, preschool, older siblings, etc.)?

0-6 mos

6-12 mos

12+ mos