Parents, to expedite the BrainSTEPS consultation and training support services for your child, after an online referral is made, please fill out & sign the Parent Consent Form below. This consent form provides your authorization to request/release confidential information about your child to and from BrainSTEPS.

City / State / Zip

*If you do not know what Intermediate Unit (IU) provides services to your county:
1. Click “ABOUT US” in the menu above.
2. From the dropdown menu, choose “FIND YOUR BRAINSTEPS TEAM.”
3. Search for the correct Intermediate Unit BrainSTEPS name by county that your child lives in.

to obtain/release records and information regarding my child, as well as conduct a school day observation of my child if BrainSTEPS determines it is needed:
Student Name
Student Date of Birth
Parent/Guardian/Surrogate Phone Number
Parent/Guardian/Surrogate Email
Please include name, phone number, fax number for the following as appropriate:

Place an X below to designate specific reports, records, and/or phone contact to be released to your child’s BrainSTEPS Team:

This authorization/permission to share information does not expire. I understand that my child’s BrainSTEPS team will work with my child’s school team to determine brain injury-related school supports. I also understand that my signature provides consent for my child’s referral information, consultation activities, and related information to be entered into the BrainSTEPS Program’s database, which is a secure site.

Signature of Parent/Guardian/Surrogate


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