<p> Early Childhood Special Education Referral for Screening PGC 101e Parent Consent Form Peace Garden Special Services 309 2nd St East Bottineau, ND 58318 Referring Information Referring Agency/Program/Person: Phone: </p><p>Referral Date: / / Date Received in PGSS Office: / / Child/Parent Contact Information Child: Date of Birth: / / Parent/Guardian: Address: Home Phone: Cell/Work Phone: Parent Consent and Release of Information</p><p>I give permission for (agency/program/person) to complete a screening with my child and share all pertinent information (child’s name) with Peace Garden regarding Special Services to provide feedback to the referral source.</p><p>Parent Signature: Date: Screening and Referral Information State approved screening tool to be administered: (Please attach copy of child’s screening protocol) Battelle Developmental Inventory Screening Brigance Screening II Brigance Screening III</p><p>Concerns for possible delays in the following areas (please check all areas of concern): adaptive/self help cognitive/problem solving social-emotional behavior fine motor gross motor hearing speech and language vision other: </p><p>Identified condition or diagnosis known to have a high probability of resulting in significant developmental delays (Please describe): </p><p>Developmental risk factors (medical or psychosocial) please describe: </p><p>Further comments: ECSE Referral Feedback</p><p>PGSS ECSE Personnel- please complete this portion and return to referral source above. PGSS staff member responsible: (staff member’s name)</p><p>The child was screened on / / (date) and further evaluation is: recommended not recommended</p><p>Feedback sent/given to referring agency/program/person on / / (date).</p><p>Comments: </p>