Appendix E - Summary of Parent Consents for the Transition Process and Sample Parent Consent Forms

 

Parent Consent Requirement Date Requested Date Received
Written consent to notify the school district in which the child resides of the child’s potential eligibility for services under Section 4410 of the Education Law (notification must be completed at least 120 days prior to the date the child is first eligible for such services).  10 NYCRR 69-4.20(b) . .
Written consent for the Early Intervention Official to arrange for a transition conference (the transition conference must be convened at least 90 days prior to the date the child is first eligible for services under Section 4410 of Education Law or the child’s third birthday, whichever is first).  10 NYCRR 69-4.20(b)(3) . .
Written consent to refer the child to the Committee on Preschool Special Education, in the school district where the child resides. . .
Written consent for evaluation of the child by the CPSE.  Part 200.5(b)(1)(i) . .
Written consent to allow the service coordinator to forward evaluation and other EIP records for review by the CPSE, to assist in completion of the child’s evaluation by the CPSE.  10 NYCRR 69-4.20(b)(2) 3 . .
Written consent to incorporate the transition plan into the IFSP.  10 NYCRR 69-4.20(a)(2)(iii) . .
Written consent for the IEP.  Part 200.16(g)(7)(Part 200.5(b)(1)(ii) . .
If the child will continue in the EIP, written consent to continue the services in the IFSP until the child is no longer age eligible, or until the date at which the parent elects to transition the child, if earlier.  10 NYCRR 69-4.11(a)(8) . .
Written consent to notify the school district that the child will remain in the EIP until the child ages out.  10 NYCRR 69-4.20(d) . .
Written consent to transmit EIP records to providers of preschool special education programs and services, at the time the child transitions to these services.  10 NYCRR Section 69-4.17(c)(5) 4 . .

 

 

SAMPLE CONSENT FORM

<NAME OF COUNTY> - EARLY INTERVENTION PROGRAM

 

CONSENT FORM FOR TRANSITION NOTICE

 

DATE: .
Child's Name

Last                                         First

 EI #:
Name of Parent/Legal Guardian

Last                                         First

 Phone No.
Home Address:

 

 School District:
Service Coordinator:

 

 Phone No.
Early Intervention Official/Designee:

 

 Phone No.
CPSE Chair:

 

 Phone No.

 

 

Please Read

I understand that to ensure my child continues to receive services on and after his/her third birthday, s/he must be referred to, evaluated by, and before his/her third birthday, found eligible for preschool special education programs and services by the Committee on Preschool Special Education of my local school district (the district in which my child resides). 

 

I understand that as of my child’s third birthday, my child will no longer be eligible for the Early Intervention Program unless s/he has been found eligible for preschool special education programs and services.  EIP services will end the day before my child turns three years old.

 

 

 

Consent to Notify the School District

         I give my consent to the <Name of County> Early Intervention Program to notify my school district that my child may be eligible for preschool special education programs and services.

 

         I do NOT give the <Name of County> Early Intervention Program consent to notify school district that my child may be eligible for preschool special education programs and services under Section 4410 of the Education Law.  I understand that my child must be referred to, evaluated by, and before the day s/he turns three years of age, be found eligible by the CPSE for services, to continue to receive Early Intervention Program services on and after s/he turns three years of age. 

 

______________________________________________________________________________

Parent Name                                                                     Parent Signature                                 Date

 

 

 

 

SAMPLE CONSENT FORM

<NAME OF COUNTY> - EARLY INTERVENTION PROGRAM

 

CONSENT FORM FOR TRANSITION CONFERENCE

 

DATE: .
Child's Name

Last                                         First

 EI #:
Name of Parent/Legal Guardian

Last                                         First

 Phone No.
Home Address:

 

 School District
Service Coordinator:

 

 Phone No.
Early Intervention Official/Designee:

 

 Phone No.
CPSE Chair:

 

 Phone No.


Please Read

I understand that to ensure my child continues to receive services on and after his/her third birthday, s/he must be referred to, evaluated by, and before his/her third birthday, found eligible for preschool special education programs and services by the Committee on Preschool Special Education of my local school district (the district in which my child resides). 

 

I understand that as of my child’s third birthday, my child will no longer be eligible for the Early Intervention Program unless s/he has been found eligible for preschool special education programs and services.  EIP services will end the day before my child turns three years old.

 

 

 

Consent to Convene a Transition Conference

 

         I give my consent to the <Name of County> Early Intervention Program to arrange a transition conference, which will include the EIO, my service coordinator, and chairperson of the CPSE or his/her designee, to discuss my child’s referral to the CPSE, program and service options, and develop a transition plan.  I also consent to the following agency(ies) or individual(s) attending: ______________ ______________________________________.

 

        I do NOT wish to have the <Name of County> Early Intervention Program convene a transition conference.  I understand that my child must be referred to, evaluated by, and, before the day s/he turns three years of age, be found eligible by the CPSE for services, to continue to receive Early Intervention Program services on and after s/he turns three years of age.

 

 ______________________________________________________________________________________

Parent Name                                                                     Parent Signature                                 Date

 

 

 

 

SAMPLE CONSENT FORM
<NAME OF COUNTY> - EARLY INTERVENTION PROGRAM

 

CONSENT FORM FOR REFERRAL TO THE
COMMITTEE ON PRESCHOOL SPECIAL EDUCATION

 

DATE: .
Child's Name

Last                                         First

 EI #:
Name of Parent/Legal Guardian

Last                                         First

 Phone No.
Home Address:

 

 School District
Service Coordinator:

 

 Phone No.
Early Intervention Official/Designee:

 

 Phone No.
CPSE Chair:

 

 Phone No.


 

I understand that to ensure my child continues to receive services on and after his/her third birthday, s/he must be referred to, evaluated by, and before his/her third birthday, found eligible for preschool special education programs and services by the Committee on Preschool Special Education of my local school district (the district in which my child resides). 

 

I understand that as of my child’s third birthday, my child will no longer be eligible for the Early Intervention Program unless s/he has been found eligible for preschool special education programs and services.  EIP services will end the day before my child turns three years old.

 

 

CONSENT FOR REFERRAL TO THE
COMMITTEE ON PRESCHOOL SPECIAL EDUCATION

 

        I give my consent to <Name of County> Early Intervention Program to refer my child to the CPSE of the school district in which my child resides for an evaluation to determine whether s/he is eligible for preschool special education programs and services.

 

         I do NOT give the <Name of County> Early Intervention Program my consent to refer my child to the CPSE of the school district in which my child resides for an evaluation to determine whether s/he is eligible for preschool special education programs and services.  I understand that my child must be referred to, evaluated by, and, before the day s/he turns three years of age, be found eligible by the CPSE for services, to continue to receive Early Intervention Program services on and after s/he turns three years of age.  I understand that I may directly refer my child for an evaluation by the CPSE, and that other individuals may also refer my child to the CPSE.   I understand that if I choose to refer my child directly, I must refer my child within enough time (CPSE is required to make decisions within 30 school days from receipt of referral) for the CPSE to decide whether my child is eligible for services under Section 4410 of the Education Law by the day before s/he turns three years old if I want my child to continue to receive Early Intervention Program services on and after s/he turns three years of age.

 
________________________________________________________________________

Parent Name                                                                     Parent Signature                                 Date
 


SAMPLE FORM

<NAME OF COUNTY> - EARLY INTERVENTION PROGRAM

 

CONSENT FORM FOR TRANSMITTAL OF
EIP EVALUATIONS AND RECORDS TO THE CPSE
 

DATE: .
Child's Name

Last                                         First

 EI #:
Name of Parent/Legal Guardian

Last                                         First

 Phone No.
Home Address:

 

 School District
Service Coordinator:

 

 Phone No.
Early Intervention Official/Designee:

 

 Phone No.
CPSE Chair:

 

 Phone No.

Please Read

I understand that the CPSE may use evaluation reports and other EIP records, which I may choose to share, as part of the CPSE evaluation process.  I decide what records to share, if any.  If I consent to share these records, the CPSE will review them and will decide if other evaluations are necessary to decide if my child is eligible for preschool special education programs and services.  I understand that if the CPSE asks for more evaluations, I will be asked for my consent to evaluate my child.  I understand that if I do not consent to evaluations asked for by the CPSE, and my child is not evaluated by the CPSE and is not determined eligible for preschool special education programs and services by my child’s third birthday, EIP services will end the day before my child turns three years old. 

 

Consent to Transmit EIP Evaluation and Program Records to the CPSE
 

       I give my consent to the <Name of County> Early Intervention Program to transmit the attached list of EIP reports and records to the CPSE of the school district in which my child resides.

 

      I do NOT give the <Name of County> Early Intervention Program consent to transmit EIP records and reports to the CPSE to the school district in which my child resides.  I understand that my child must be referred to, evaluated by, and, before the day s/he turns three years of age, be found eligible by the CPSE for services, to continue to receive Early Intervention Program services on and after s/he turns three years of age. 

 

 

_______________________________________________________________________________________
Parent Name                                                     Parent Signature                                   Date

3 Parents have the right to sign either a general release or selective release, which specifies by name or category those individuals to whom information may be disclosed.

4 Parents have the right to choose which records and reports, if any, are transmitted to the CPSE.