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It records the referral source, selected screening or observation reasons, and specific areas of concern such as cognitive/educational, communication, motor, social/emotional, hearing, vision, and health. 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Child Contact Information  \nChild’s Name:   Child’s Gender: □ Male □ Female Child’s Address:   Child’s Date of Birth:    \nParent/Guardian Name:   Relationship to Child:  Address:   Phone:   Child’s Primary Language:  Local Education Agency Name:   Local Education Agency Address:    \nSection 2. Early Care and Education Program Contact Information  \nEarly Care and Education Program Name:   Early Care and Education Program Address:    \nContact Person:    \nContact Phone \\#:  Contact Email:    \nSection 3. Primary Care Provider Contact Information  \nChild’s Primary Care Provider Name:   Child’s Primary Care Provider Address:   Contact Person:    \nContact Phone \\#:  Contact Email:    \nSection 4. Reason(s) for Referral  \nName of Person/Entity Making the Referral:   Reason for Referral (choose all that apply)  \n□Screening Results □Teacher Observation □Parent Request □Transitioning from Early Intervention  \nAreas of Concern (choose all that apply):  \n□Cognitive/Educational □Communication □Motor □Social/Emotional □Hearing □Vision □Health  \nCOMMENTS:  \nSection 5. Authorization to Release Information  \nI,   (name of parent or guardian), give my permission for my child’s primary care provider,   (print name of provider), to share pertinent information about my child,   (print name of child) regarding suspected developmental delay or related medical conditions with the child’s Early Child Care and Education Program. I understand that I may withdraw this consent by written request to my child’s primary care provider, except to the extent it has already been acted upon.  \nYour consent allows the child’s Early Child Care and Education Program,   (insert name of early child care and education program), to share reports and results related to the child’s suspected developmental delay with your child’s primary care provider listed above in Section 3. I understand that I may withdraw this consent by written request to my child’s Early Child Care and Education Program, except to the extent it has already been acted upon. I certify that this Authorization to Release Information has been given freely and voluntarily. Information collected hereunder may not be re-disclosed unless the person who consented to this disclosure specifically consents to such redisclosure and/or the re-disclosure is allowed by law. I understand that I have a right to inspect and copy the information to be disclosed.  \nSignatures  \nParent/Guardian*:  \nName Printed Signature Date  \n* Consent is effective for a period of12 months from the date of you signature on this Release  \nIndividual Authorized to sign for Early Care and Education Program:  \n__________________________________________________________________________________________________  \nName Printed Signature Date","cbCaitIYEae9aHBc","https://ap.wps.com/l/cbCaitIYEae9aHBc","pdf",255271,"English","# Section 1: Child Contact Information\n# Section 2: Early Care and Education Program Contact Information\n# Section 3: Primary Care Provider Contact Information\n# Section 4: Reason(s) for Referral\n# Section 5: Authorization to Release Information","[{\"question\":\"What information is collected about the child in Section 1?\",\"answer\":\"Section 1 requests the child’s name, gender, address, and date of birth, along with the parent/guardian name and relationship, phone, primary language, and the local education agency name and address.\"},{\"question\":\"How are the reasons and areas of concern for referral selected in Section 4?\",\"answer\":\"Section 4 includes checkboxes to choose the referral reason(s) such as screening results, teacher observation, parent request, or transitioning from early intervention. It also allows selecting areas of concern including cognitive/educational, communication, motor, social/emotional, hearing, vision, and health, with an optional comments field.\"},{\"question\":\"What does the authorization in Section 5 allow, and how can consent be withdrawn?\",\"answer\":\"Section 5 authorizes information sharing between the child’s primary care provider and the early child care and education program regarding suspected developmental delay or related medical conditions. It states consent may be withdrawn by written request to the relevant provider or program, except to the extent already acted upon, and includes signature and certification requirements.\"}]","Standardized Request - Early Childhood Special Education - Evaluation | PDF",1791604557]