Consent to Evaluate

Consent to Evaluate

I hereby consent to the following evaluation for my child for the purpose of determining eligibility for services in the Early Intervention Program.
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Evaluation(s) to be completed*
Name of Evaluator*
Discipline*
Name of Evaluator
Discipline
Name of Evaluator
Discipline
Name of Evaluator
Discipline
Name of Parent/Guardian*

First NameLast Name
Phone Number*

Area CodePhone Number
Signature of Parent/Guardian*

Clear
Date*

MonthDayYear
Date
Please send a copy of this evaluation to my pediatrician listed below*

YesNo
In order to complete the evaluation packet, the enclosed Health Form must be completed by your pediatrician and given to the evaluators on the day of the evaluation. If it will be difficult for you to have the form completed, you may sign the following consent so we may contact the pediatrician directly. However, we do request that if at all possible, you have the health form at the time of the evaluation.

I hereby consent for Little Angels Center, Inc to assess my child’s immunization record and current health status for the purpose of completing a developmental evaluation.
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
Pediatrician's Name

First NameLast Name
Pediatrician's Phone Number

Area CodePhone Number
Pediatrician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty: