{Insert Name of Agency}

Screening Consent/Waiver – Form

Review this form very carefully. Be sure to ask questions about anything you do not understand.

______________________________________________________________________________

I do not want to be screened for learning disabilities at this time.

If you do not want to be screened for a learning disability at this time:

1. This program will not give you any special treatment because of a learning disability unless a screening and evaluation show that you have one.

2. You may change your mind and ask for a learning disabilities screening at any time.

I would like to be screened for learning disabilities at this time

If you accept screening for learning disabilities at this time:

1. You may be entitled to specialized instruction and accommodations.

2. Screening results will be shared with you, the intake specialist, your tutor and/or teacher only. For the results of your screening to be released to anyone else you must sign a Release of Information form.

3. Screening results will be used to assist your teacher/tutor in planning instruction.

4. Recommendations may be made by the examiner for further screening or evaluation. You have no obligation to accept further screening.

5. Screening results will become part of your permanent file.

Name of Screening Test Given: ______________________________________________

Date of Screening: ________________________________________________________

I have read this form or had it read to me. I understand the information on this form and understand my decision regarding learning disability screening.

Printed Name:_______________________________________________________________

Signed Name:________________________________________________________________

Today’s Date: ________________________________________________________________