Apalachicola Bay Charter School
Parental Notice and Consent for Screening and Intervention Activities in the MTSS Process
Student:________________________________________________ Grade:_______
Dear Parent/Guardian,
It is the Mission of the Apalachicola Bay Charter School that each child reach their academic and
social potential. In an effort to comply with this mission and state legislation, and maximize student success,
ABC School has an intervention/problem solving process in place called MTSS (Multi-Tiered System of
Support) to help meet student needs academically, behaviorally, socially, and emotionally. The purpose of this
team is to:
- Identify the learning needs of students struggling academically and may be at risk of failure;
- Identify the behavioral,social/emotional needs of students struggling with interpersonal and
intrapersonal relationships;
- Provide students with academic, social, emotional, and behavioral support needed to succeed
in school by conducting screenings, and implementing interventions individually and/or in small
groups with qualified school staff and/or contractors.
The MTSS team may include classroom teachers, school administrators, academic or social/emotional
interventionists, school psychologist, behavior analyst, counselor, and parents/guardians.
To help your child have a successful school year the problem solving team may need to gather more
information by administering individual screenings. By signing this consent form, you give permission for
screening including some or all of these areas: vision, hearing, speech, language, behavior, social/emotional,
cognitive, or academic concerns. Based on the results of the screenings and/or observations, academic,
behavioral, social/emotional goals and tier one and tier two interventions may be developed and implemented.
Some examples may include additional academic support provided by classroom teachers and the
reading/math interventionists, screenings for vision/hearing provided by the school nurse, behavioral
observations and/or screenings, intellectual quotient screenings, social/emotional screenings conducted by
qualified persons, individual and/or small groups focusing on academic, behavioral, social, and/or emotional
goals.
In order for ABC School to conduct the necessary screenings and implement intervention services for your
child, your consent must be obtained. All information gathered will assist in educational planning and will be
shared with you at your request.
Please check the appropriate box below, sign your name and date, and return to your child’s classroom teacher.
____ YES, I consent for my child to have screenings and interventions to aid in school success.
____ NO, I do not consent for my child to have screenings and interventions to aid in school success.
Comments:_______________________________________________________________________________
________________________________________________________________________________________
Parent Signature:_________________________________________ Date:___________________________