Occupational Therapy – Consent / Assent Form

Consent(Required)

Classroom Observation

Occuapational therapy screening

Feedback to School Staff

Caregiver Consent Form: Classroom Observation & Speech-Language Screening

Dear Parent/Caregiver,

Thank you for choosing to work with the Kerchia Naidoo Therapy Centre!

In order to support your child’s speech, language, and learning development, we request your consent to conduct a classroom observation and/or a speech-language therapy screening.

These observations and screenings are informal and non-invasive. They aim to identify any areas in which your child may benefit from support, such as attention, understanding and use of language, speech clarity, and social communication.

Please note:

This is not a formal assessment, and no diagnosis will be made at this stage.

Findings will be shared with you and, with your permission, the relevant school staff.

If any concerns are identified, we will recommend next steps or further evaluation.

Child’s Full Name(Required)

First Last

Date of Birth(Required)

School's Name(Required)

Parent/Guardian Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)