Permission to Screen Form

Moving Mountains Foundation (MMF) is pleased to offer FREE developmental screenings to all individuals interested in our community. These screenings look at all areas of functioning including communication, speech sound development, gross motor movements, fine motor movements, problem solving, emotional and social skills, and thinking. Licensed therapists will either perform the screenings or oversee trained staff and affiliates to provide these screenings. Moving Mountains Foundation works with third party community resources to ensure appropriate referrals are provided for therapy services (speech-language therapy, occupational therapy, physical therapy, mental health counseling) within our community. By filling out this permission to screen form you are giving MMF permission to share your contact and screening information with appropriate parties.

Client Name

Date of Birth

Date

If your child was born premature, please list their gestational age here

Client Preferred Name

Client Pronouns

Childcare Center/Community Site Name

Responsible Party Name

Phone Number

Responsible Party Email

example@example.com

Responsible Party Relation to Client

Prefered Contact Method (check all that apply)

Phone CallsVoicemailsText MessagesEmails

Primary Language Spoken in the Home

Other Languages Spoken

Is the Client enrolled in other therapy programs/services?

YesNo

If yes, please list

Is the Responsible Party legally able to make medical decisions for the client listed above?

YesNo

If no, please list the name and contact information for an individual who is legally able to make medical decisions for the client.

Dear Responsible Party,

If the screening indicates that the client does not need additional testing, then no further action will be required. If the screening indicates that the client presents with error patterns or delayed milestones that are developmentally inappropriate at this time, then you will be provided with community resources. If onsite therapeutic services are provided or become available at the childcare site, you will be given information on how to enroll the client for a formal evaluation with the onsite providers.

Primary Concerns

I, the Responsible Party, give permission for the client listed above, to participate in a developmental screening by Moving Mountains Foundation. I agree to Moving Mountains Foundation sharing the results of this screening with affiliated partners and community resources as applicable.

Waiver of Liability: In return for being allowed to participate in Moving Mountains Foundation’s screening and education program, the undersigned responsible party releases and agrees not to sue Moving Mountains Foundation or its officers, preferred providers, directors, employees, sub-contractors, sponsors, agents and affiliates from all present and future claims or assigns for property damage, personal injury, or wrongful death arising as a result of my participation in the screening and education program, even if caused by ordinary negligence. I also acknowledge that Moving Mountains Foundation has not arranged and does not carry any insurance of any kind for the officers, preferred providers, directors, employees, sub-contractors, sponsors, agents and affiliates. I also understand that this document is a contract that grants certain rights to and eliminates the liability of the Moving Mountains Foundation.

Disclaimer: This screening does NOT replace a formal evaluation from a licensed speech-language pathologist, or physical or occupational therapist, or a mental health counselor, diagnose a delay or disorder, or qualify your child for therapeutic services.

Responsible Party Signature

Date

phone: 406.396.4130 fax: 406.797.5008

www.movingmountainsmt.org

email:foundation@mmtherapycenter.con

Informed Consent Screening Permission Form