Child’s Name
DOB
Center
Motivation Education & Training, Inc.
SPECIAL SERVICES CONSENT FORM
Parent or guardian must initial each section indicating their understanding of the stated policy.
IDENTIFICATION AND AUTHORIZATION
MET Head Start/Early Head Start believes that your child should be scheduled for further evaluation in the following
area(s):
______________________________________________________________________________________
______________________________________________________________________________________
______ I wish to grant consent and allow my child to be referred to a professional who will help determine if he/she
could benefit from special services. I understand that my child cannot be referred to another professional
without my written consent.
PROCEDURAL SAFEGUARDS (PARENT’S RIGHT)
______ I have received a copy of “The Procedural Safeguards” for children receiving Special Education services in the
State of Texas, and it has been explained to me in native language. I understand that I must have a copy of “The
Procedural Safeguards” in order to complete the referral process.
SERVICE DELIVERY
______ I agree that MET Head Start/Early Head Start shall provide all basic services available to any child and family
enrolled in the program. Since children with disabilities may have needs that go beyond basic MET-Head
Start/Early Head Start services, the ISD/ECI shall be responsible for the provision of additional educational and
related services included in the Individualized Education Plan (IEP)/Individualized Family Service Plan (IFSP) and
not available through MET. These services, when delivered at a MET-Head Start/Early Head Start site, will be
integrated into regular classroom routine and activities. MET-Head Start/Early Head Start will provide a
supportive classroom environment as it relates to the Head Start Child Development and Early Learning
Framework.
CERTIFICATION
I give my permission for MET-Head Start/Early Head Start to refer my child, listed above, to ______________________.
I have been informed in my native language that my consent is voluntary and that I may refuse to sign this form. I also
know that if I do sign, I may withdraw my consent at any time. I am aware that I will be invited and encouraged to
attend all meetings for the specified purpose(s). I have been informed of my parental rights under the “Individuals with
Disabilities Education Act” (IDEA).
Additionally, I grant consent for my child to have unsupervised access during onsite professional therapy sessions.
Parent/Legal Guardian’s Signature
Date
Authorized Employee’s Signature
Date
Child Mental Health
Revised: 7/26/2012 - AM