Parent/Guardian Authorization for THRIVE Referral and Support
I give permission for my child to be referred to the THRIVE Collaborative, coordinated by the Early Learning Coalition of Southwest Florida (Coalition).
I authorize my child’s early learning provider to share information with the Coalition and designated THRIVE partners that is reasonably necessary to understand the concern identified in this referral and to coordinate appropriate supports. This information may include developmental screening results, observations, relevant educational or developmental information, strategies or interventions previously attempted, and information about my child’s response or progress.
I authorize the Coalition and designated THRIVE partners, as appropriate, to:
• contact me and my child’s early learning provider regarding this referral;
• review information relevant to the referral;
• observe my child in the early learning setting when appropriate;
• consult with me and my child’s provider regarding my child’s strengths and needs;
• recommend or develop strategies, interventions, or supports for use in the early learning environment;
• assist the provider with implementation of those strategies or supports;
• conduct follow-up observations and review progress-monitoring information; and
• communicate with one another as reasonably necessary to coordinate THRIVE services and supports.
I understand that participation in THRIVE is voluntary and that I may withdraw this authorization at any time by notifying the Coalition in writing. Withdrawal will not affect actions already taken based on this authorization.
I understand that this authorization does not constitute consent for medical or mental health treatment, a diagnostic evaluation, an evaluation for special education/ESE eligibility, or school district services. If THRIVE recommends services or an evaluation requiring additional parental consent or authorization, that consent will be obtained separately before those services or evaluations occur.
This authorization remains in effect while my child is actively participating in the THRIVE process or until I withdraw my authorization.