for the purpose of BrainSTEPS consultation and training.
By signing this form, you are also providing consent for the Intermediate Unit BrainSTEPS team to:
1. provide consultation and training support on behalf of your child to your child's school team;
2. input your child's required referral information, consultation activities, and related information into the BrainSTEPS Program database, which is a secure site.
I understand that following the initial BrainSTEPS consultation and training, someone from the BrainSTEPS Program will contact me annually until my child graduates from high school to determine if my child is experiencing any new or worsening brain injury-related learning issues as they age so that your child may benefit from additional BrainSTEPS support.
I understand that this authorization/permission to share information does not expire. You may withdraw your consent to share this information at any time. A request to withdraw your consent should be submitted in writing, signed, and sent to the BrainSTEPS Director, Dr. Brenda Eagan-Johnson at [email protected]