Consent for Consultation Services & Release of Records

Thank you for your interest in consultation services through Pencil & Pathways. Please complete this form to indicate your consent for services.

Explanation of Services

Licensed Specialists in School Psychology (LSSP) and Speech-Language Pathologists (SLP) work with school staff, students, and families to support academic, social, emotional, and behavioral success. Our staff are credentialed by the Texas State Board of Examiners of Psychologists and the State Board of Examiners for Speech-Language Pathology and Audiology.

Reason for Request of Services

The student is being referred by parents and/or school staff for consultation to:

Better understand and support academic, behavioral, social, or emotional needs.
Provide input regarding educational, behavioral, or learning supports.

Nature and Purpose of Proposed Services

Consultation may include one or more of the following:

Observation: The student may be observed in their educational setting. Notes may be documented and shared with relevant parties.
Meetings: The consultant may meet with parents and/or school staff to review concerns, discuss observations, interpret prior evaluations, provide education about diagnoses, or assist in developing educational/behavioral plans (e.g., IEP, 504 plan).
Collaboration: The consultant may provide strategies, resources, or recommendations to help support the student’s success.

The overall purpose of consultation is to assist in the development of systems, strategies, and supports that promote student growth and success.

Confidentiality

All services are provided in a manner that safeguards privacy and confidentiality. Limits of confidentiality include risks of harm to self or others, suspected abuse or neglect, and other situations required by law.

Information may be shared with parents/guardians and relevant school staff as necessary to support consultation goals. Written consent will be obtained for release of records to outside professionals or agencies.

Reference: TSBEP Rule 465.12, Privacy and Confidentiality.

Disclaimer

Consultation is an educational support service, not a psychological evaluation or therapy. Diagnoses are not provided as part of consultation, and insurance is not billed for this service. If further assessment or therapy is recommended, an appropriate referral will be made.

Maintenance of Records

Pencil & Pathways maintains records in accordance with state and federal law, including TSBEP Rule 465.22. Records will be stored securely for at least seven years after termination of services, or three years after the student reaches the age of majority, whichever is longer.

Billing and Payment

Psychological services are provided at your child’s school. In accordance with Texas State Board of Examiners of Psychologists (TSBEP) rules and regulations, invoices will be issued to the school. Families will receive an estimate in advance and be copied on the invoice for transparency; however, payment is made directly to the school, not to the provider

Consent

By signing below, I consent for Pencil & Pathways to provide consultation services for my child, which may include observation, meetings, and communication with school staff, and to maintain records of these services as described above.

Parent Name

First Name

Last Name

Student Name

First Name

Last Name

Student's Birthdate

YYYY

Student's School

Phone

(###)

###

####

I have read and understood the Informed Consent above. I give permission for my child to participate in the described consultation services with Pencil & Pathways.

Yes

Type Full Name as Signature

I understand that, as part of the consultation process, the evaluator may need to communicate with school staff (such as teachers, special education personnel, or administrators) to gather relevant information about my child’s academic, behavioral, and social-emotional functioning. I give permission for the evaluator to contact and collaborate with school personnel.