Harvesting Hope Community Screening Event

Harvesting Hope: Pediatric Developmental Screening

Parent Registration & Consent Form
Purpose of the Event
Somos Bilingües is proud to host Harvesting Hope, a free community event designed to support families who may have concerns about their child’s development. Screenings are offered by licensed professionals in the areas of speech and language, occupational therapy, physical therapy, psychology, and social work.

There is no cost to families for participation.

Understanding the Difference Between a Screening and an Evaluation

A developmental screening is a brief, play-based observation lasting approximately 10–15 minutes. It is designed to provide a general overview of your child’s developmental skills and determine whether a more comprehensive evaluation may be beneficial.

A screening is not an evaluation or diagnosis.
It does not confirm or rule out any developmental disorder, delay, or disability, and results should be considered preliminary guidance only.

Next Steps if Concerns Are Identified
If the results of the screening suggest that your child may benefit from a more comprehensive evaluation, you will receive guidance on available options:
- Birth to 3 years: You may elect to request a free evaluation through the New York State Early Intervention Program.
- Ages 3–5: You may request a free evaluation through your local school district’s Committee on Preschool Special Education (CPSE).
- Kindergarten to 12th grade: You may request a free evaluation through your school district’s Committee on Special Education (CSE).
- Private Option: Families may also choose to pursue a private evaluation through Somos Bilingües at their discretion.
- Parent/Guardian Responsibilities
  A parent or legal guardian must remain with their child at all times during the event and screening.
- Parents are responsible for supervising their child before, during, and after the screening.
- If a child becomes distressed or uncooperative, the screening may be paused or discontinued to ensure the comfort and safety of all participants.
- Late arrivals may result in reduced or forfeited screening time.
I would like for my child to be screened in the following areas:*

Speech and LanguageFeedingOccupational TherapyPhysical TherapyPsychologicalAutism
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Parent's Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Liability Disclaimer
By signing this consent form, I understand and agree that:

1. This screening is a voluntary community service provided by Somos Bilingües at no cost.

2. Somos Bilingües and its staff are not liable for:
- Screening results that may not align with parental opinions or expectations.
- Screenings that cannot be completed due to a child’s behavior, limited cooperation, or time constraints.
- Any decisions or actions taken by the parent/guardian following the screening results.
3. I understand that the screening does not create a provider-patient relationship, nor does it substitute for individualized medical, developmental, or educational evaluation.

4. I release Somos Bilingües, its staff, contractors, and volunteers from any and all liability related to participation in this event.

Consent to Participate
1. I understand this is a free community screening intended to provide general information about my child’s development.
2. I understand this is not a diagnostic evaluation and will not result in a formal diagnosis.
3. I voluntarily consent to my child’s participation in the screening conducted by Somos Bilingües staff.
4. I understand that the results will be shared directly with me and will remain confidential.
Parent Signature*

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Harvesting Hope: Pediatric Developmental Screening