Child’s Name:____________________________ 	Date:____________________
Center:________________ Observation completed by:________________________

PARENT/GUARDIAN CONSENT FOR ADDITIONAL SCREENING

Hello,

I observed your child due to receiving a Teacher Concern Sheet that was initiated by you or your child’s teachers.  
 I would like to have your child’s teacher complete a Devereux Early Childhood Assessment (DECA) form. The DECA is a strengths-based tool designed to support early intervention efforts to reduce and/or eliminate significant emotional and behavioral concerns in preschoolers, between the ages of 2 and 6. This tool is comprised of 62 questions and takes 15 minutes for a teacher or parent to complete.
Below is a consent form for your signature.  Please leave the consent form with your child’s teacher.

DECA to be completed by: __________________________________________

Area of concern: ____________________________________________________

In granting consent, I understand that such information will remain confidential, and that such information will be used to provide the child named above the best professional services.  I also understand that this consent is valid from date signed.   The undersigned parent/guardian will be notified of the results. 

Initial:
_____ I give permission for my child’s Matrix Head Start teacher to fill out a DECA.
_____ I do not give permission for my child’s Matrix Head Start teacher to fill out the DECA. 
_____ I am interested in completing a DECA. 

Signature Parent/ Guardian ___________________________ Date ____________

I

 Matrix Head Start

1400 Woodbridge

Detroit, MI         
48207

p. 313 962-5255
f. 313 962-5253

Funded by the

US Department of

Health & Human Services