Consent for Developmental and/or Speech-Language Screenings
Pencil & Pathways, PLLC
Thank you for your interest in screening services through Pencil & Pathways. Early identification of developmental and communication difficulties provides the best opportunity for early support and intervention.
Description of Services
Licensed Specialists in School Psychology (LSSPs) and Speech-Language Pathologists (SLPs) collaborate with school staff to support students’ academic, social, and emotional development. These professionals are credentialed by the Texas State Board of Examiners of Psychologists and the Texas State Board of Examiners for Speech-Language Pathology and Audiology.
Purpose of Screening
Your child has been referred by school personnel and/or a parent/guardian for a screening to determine whether developmental and/or speech-language concerns warrant further evaluation.
Scope of Services
Screenings are brief, structured assessments intended to identify whether further evaluation is recommended. As part of the screening:
Parent and teacher input will be gathered via electronic forms.
Your child may be individually screened in one or more of the following areas: speech articulation, expressive/receptive language, and/or developmental functioning.
A summary report (1–2 pages) will be provided to indicate whether further assessment is recommended.
Confidentiality
All services are conducted in accordance with state and federal laws regarding confidentiality. Pencil & Pathways adheres to Texas State Board of Examiners of Psychologists Rule §465.12, Chapter 611 of the Texas Health and Safety Code, HIPAA (as applicable), and FERPA when working in educational settings.
Information shared will remain confidential except as required or permitted by law.
Information may be discussed in consultation with supervising professionals or school personnel involved in your child’s support, with identifying details limited to what is necessary.
No reports or records will be shared outside of the school or clinical team without written consent, unless required by law (e.g., in cases of abuse, harm to self/others, or legal subpoena).
Records and Documentation
Records are maintained in compliance with TSBEP Rule §465.22 and applicable federal laws.
All documentation is stored securely and retained for a minimum of 7 years, or until the student is at least 21 years old—whichever is later.
Reports will include only information relevant to the purpose of the screening.
You may request a copy of your child’s records by submitting a written request.
Informed Consent
By signing below, you acknowledge that you understand the nature and purpose of the screening services, as well as your rights regarding confidentiality and records. You are giving consent for Pencil & Pathways providers to conduct the screening and communicate with relevant school personnel to support your child.
If there are any significant changes in the nature or scope of services, updated consent will be requested.