Page 1

Educational Service Unit 10 76 Plaza Boulevard ~ PO Box 850 Kearney, NE 68848-0850 Ph. 308.237.5927 ~ Fax 308.237.5920

Request for Behavioral Screening and/or Consultation Student Date of Birth Parent(s) Home phone

______________________________ School _____________________________________ ______________________________ Grade _____________________________________ ______________________________ Teacher _____________________________________ ____________ Work phone ____________ Other phone _______________

Referred by: Student Assistance Team (SAT), 504 Team, IEP Team Name of SAT, 504, or IEP Contact Person _________________________________ Parent Doctor (or other professional) Name of referring professional _________________________________________ Reason for referral:

Outcome(s) expected as a result of the referral:

Check one of the following to Consent, Request Conference, or Deny Consent: ______ I am aware of the above-listed reasons for my child’s referral and DO GIVE CONSENT for screening and consultation completed by the ESU 10 School Psychologist. ______ I am aware of the above-listed reasons for my child’s referral but WISH TO CONFERENCE with a school representative and the ESU 10 school psychologist before giving or denying consent for screening and consultation. To schedule this conference, I can be reached at (list at least two options): Day of the week __________ time ______ at phone number __________________ Day of the week __________ time ______ at phone number __________________ ______ I am aware of the above-listed reasons for my child’s referral and DO NOT GIVE CONSENT at this time for screening and consultation completed by the ESU 10 School Psychologist. Check the following to provide release of information: ______ If one expected outcome of this referral is consultation with an outside service provider (for example, a doctor or therapist), I also GIVE CONSENT FOR EXCHANGE OF INFORMATION between the ESU 10 School Psychologist and the professional listed below: Name _______________________________________________________ Address _____________________________________________________ _____________________________________________________ Phone _____________________ Fax ___________________________

Parent Signature _________________________________________

Date _____________________ pf 5/2004

Request%20for%20Behavioral%20Screening%20(3)  

http://www.esu10.org/file_uploads/Request%20for%20Behavioral%20Screening%20(3).pdf

Read more
Read more
Similar to
Popular now
Just for you