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 State of Illinois
Department of Human Services - Migrant & Seasonal Head Start

PARENT/GUARDIAN CONSENT FOR DEVELOPMENTAL SCREENING

I give my permission for Marion Parham

to receive from
(Name of the Child)
Stephen F. Austin

State University staff and from Majesty Parker the following:

(Name of the Center) (Name of Center's Mental Health Consultant)

✓Yes No DENVER II

Yes
/ No QUESTIONNAIRE: SOCIAL-EMOTIONAL

Yes ✓No CLASSROOM OBSERVATION BY THE MENTAL HEALTH CONSULTANT

Also, I authorize the exchange of information about my child between the center's staff and the consultant named above.

This permission is valid until

"
11120120
la Kisha McCall 11118120
Signature of parent/guardian Date

Developmental screenings will be done to make sure that your child's development stands within the expected range.
The mental health consultant will observe all children in the program. If there are any concerns and further evaluations
are recommended, you will be informed and a new parent consent will be required, before anything can be done.

At time of enrollment

IL444-4106 (R-7-09) Page 1 of 1