Screening & Therapy Consent Form

Bragg Creek Education Services Association

Early Childhood Intervention Service Provider

SCREENING, ASSESSMENT and BCESA THERAPY SERVICES

CONSENT FORM 2026-2027

Alberta Education provides Early Intervention funding for those children who demonstrate a need and are registered for the upcoming preschool/kindergarten year. Upon receipt of this signed parental consent, your child will be observed in their classroom setting by BCESA’s Educational Team, which consists of, Teachers and Therapists, and may be recommended to receive a formal assessment where you will then be contacted to discuss the results. Upon parent consent, qualifying children will receive therapy services and Early Intervention programming by BCESA’s Educational Team.

Child's First Name

Child's Last Name

Birthday

Year

Month

Day

Gender

Male

Female

Country of Birth:

Province (if Canada):

Citizenship Status:

Parent/Guardian's Names:

Address

Phone

Email

Preferred Communication:

School/Daycare Attending:

Teacher/Director:

What school year will your child be attending Kindergarten?

By checking each statement and signing below, the Parent/Guardian mentioned above acknowledges, agrees, and provides informed consent to the following terms and conditions provided by Bragg Creek Education Services Association (BCESA) and their Educational Team (including Education Coordinator, Speech-Language Pathologist, Occupational Therapist, Behaviour Strategist and Physiotherapist):

I consent to the BCESA Educational Team observing and conducting an initial screening of my child’s skills and abilities in the classroom environment.

I understand and agree that if concerns are identified during the screening, the BCESA Educational Team may proceed with a formal assessment of my child.

I understand that the BCESA Educational Team will contact me to review the results of any assessments before implementing therapy services or interventions.

I consent to my child receiving classroom support and therapy services from qualified professionals assigned by BCESA, if my child is determined to be eligible for Alberta Education funding.

I understand that eligibility for Alberta Education funding includes assignment of an Alberta Student Number and a special education Code based on my child’s assessment outcomes.

I agree that the BCESA Educational Team will develop goals for my child’s Individualized Program Plan (IPP) and provide Early Intervention services and consultation as needed.

I understand that all BCESA services and therapy supports will be delivered at my child’s school or daycare setting.

I consent to the sharing of relevant information (including therapy plans, program plans, assessment results, and summary reports) between BCESA clinicians, the school team, and Alberta Education, to support integrated service delivery.

I authorize the BCESA Educational Team to communicate with my child’s teachers, educational assistants, and other team members or allied professionals via email, telephone, or in-person meetings regarding my child’s programming and support needs.

I consent to the sharing of assessments and therapy information across disciplines within BCESA, and the inclusion of prior formal reports to ensure continuity and coordination of care.

I give permission for photos and/or videos of my child to be taken during therapy activities for the purpose of monitoring and recording progress, and for my own review.

Yes, I give permission

No, I do Not give permission

By signing below, I confirm that I have read and understood the terms of this agreement. I voluntarily provide informed consent for BCESA to conduct screening, assessment, and therapeutic services for my child, as outlined above.

Parent/Guardian Signature

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Date

Year

Month

Day