Informed Consent for Evaluation Services & Consent to Release Records

Thank you for your interest in services through Pencil and Pathways. Please review the information below regarding the nature of services, your rights, and our obligations. Your signature at the end of this form will indicate your informed consent to proceed.

Explanation of Services

Licensed Specialists in School Psychology (LSSPs) and Speech-Language Pathologists (SLPs) collaborate with school personnel and families to support students’ academic, social, and emotional success. These professionals are licensed by the Texas State Board of Examiners of Psychologists and the State Board of Examiners for Speech-Language Pathology and Audiology.

Reason for Referral

The student is being referred for evaluation or consultation by school personnel and/or a parent/guardian for the following reason(s):

To determine the presence of a disability (e.g., Learning Disability, Dyslexia, Autism Spectrum Disorder, Speech/Language Impairment, etc.) that may be impacting the student's academic functioning and to assess potential eligibility under Texas Education Agency criteria.

Nature and Purpose of Proposed Services

Depending on the referral question, one or more of the following may be provided:

Psychological Evaluation: May include clinical interviews, observations, standardized cognitive and/or achievement testing, and rating scales. Input from parents, teachers, and the student will be sought. The results will be summarized in a written report and discussed with you.
Speech and Language Evaluation: Assessment of receptive, expressive, and pragmatic language; speech production; fluency; and/or voice.

You will receive a copy of the final report and an opportunity to review the findings.

Purpose/Goals of Services

The evaluation aims to:

Identify potential areas of disability.
Clarify learning, behavioral, or emotional needs.
Assist in developing evidence-based interventions and academic goals.

Confidentiality

We are committed to maintaining the confidentiality of all client information. Information shared during services will be protected in accordance with:

Chapter 611 of the Texas Health and Safety Code,
HIPAA (where applicable),
FERPA (for services in educational settings),
And other relevant federal and state laws.

Information may only be shared with your written consent, except as required by law (e.g., risk of harm, abuse reporting, court order). For consultation purposes, only non-identifiable information will be used unless otherwise permitted by law or consent.

Psychological Records

Records are maintained in compliance with TSBEP Rule §465.22. This includes:

Secure storage of all client information.
Retention of records for a minimum of seven (7) years after the conclusion of services, or three (3) years after the individual turns 18, whichever is longer.
Timely access to records upon written request, unless release would likely result in harm to the client (as determined by the licensee in accordance with the law).

Records may include test protocols, scoring sheets, reports, interview notes, and communication logs. You may be responsible for reasonable copying or administrative fees associated with a records request.

Your Consent

By signing below, you confirm that:

You have read and understood this document.
Your questions have been answered to your satisfaction.
You consent to the services described above.
You understand you may revoke this consent at any time, in writing, unless action has already been taken based on prior consent.
Your information is secure and will only be used to coordinate services and maintain necessary records in compliance with Texas and federal privacy laws.

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 evaluation services with Pencil & Pathways.

Yes

Type Full Name as Signature

I understand that, as part of the evaluation 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 to support a comprehensive and accurate assessment.