Consent for Developmental Screenings
Nature and Purpose of Developmental Screening
Pencil & Pathways provides developmental screening for preschool-aged children using the Developmental Indicators for the Assessment of Learning–Fourth Edition (DIAL-4).
The DIAL-4 is a standardized developmental screening measure designed to identify young children who may benefit from additional monitoring, support, or comprehensive evaluation. Screening includes activities in the areas of:
Motor development
Concepts, including early cognitive and pre-academic skills
Language development
Parent and/or teacher information may also be used to provide additional information regarding the child's self-help and social-emotional development.
The screening is intended to provide a brief picture of the child's current developmental functioning and identify areas of relative strength or potential concern.
Limitations
The DIAL-4 is a screening instrument, not a comprehensive evaluation. Results should be interpreted within the limited purpose and scope of developmental screening.
Screening results:
do not establish or rule out a developmental, psychological, educational, speech-language, occupational therapy, or medical diagnosis;
do not independently determine eligibility for special education services or Section 504 accommodations;
do not replace a comprehensive evaluation when one is indicated; and
reflect the child's performance under the conditions present at the time of screening.
A child may perform within expected limits on the DIAL-4 and still have developmental needs that warrant additional evaluation. Similarly, a screening result suggesting an area of concern does not establish that a developmental disorder or disability is present.
Results and Recommendations
Following the screening, the parent/guardian will receive information regarding the child's screening results and any recommendations for monitoring, intervention, consultation, or additional evaluation.
When indicated, Pencil & Pathways may recommend further evaluation by an appropriately qualified professional, such as a psychologist, speech-language pathologist, occupational therapist, physician, or other developmental specialist.
Confidentiality
Information obtained through screening services is treated as confidential in accordance with applicable law and professional standards.
Confidentiality is subject to legal and professional exceptions, including circumstances in which disclosure is required or permitted by law.
Information will not automatically be released to a school or outside provider merely because that individual or organization referred the student. When authorization is required, a separate Authorization to Release/Exchange Information will be obtained.
Financial Arrangements
Each Developmental Screening costs $145. The school of record will bill the responsible party.
Separated or Divorced Parents
The parent or guardian initiating services represents that they have legal authority to consent to screening services for the student.
If Pencil & Pathways becomes aware that parental rights have been modified by a divorce decree, custody order, parenting plan, or other court order, relevant documentation may be required before services begin.
Electronic Communication
Pencil & Pathways may use electronic communication for scheduling, administrative communication, delivery of screening information, and other practice-related purposes.
Reasonable safeguards are used to protect confidential information; however, electronic communication carries inherent privacy and security risks.
Consent and Acknowledgment
By signing below, I acknowledge that:
I have read and understand this Informed Consent for Screening Services.
I understand the purpose and limited scope of the screening.
I understand that the DIAL-4 is a developmental screening instrument and that the results do not constitute a comprehensive evaluation or diagnosis.
I understand that screening does not determine IDEA or Section 504 eligibility.
I understand that additional evaluation may be recommended based on the screening results.
I have provided accurate information regarding my authority to consent to services for the student.
I voluntarily consent to screening services for the student identified above.