P.S. 333 Screening

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P.S. 333 Screening

P.S. 333 is participating in a new program to promote early identification of emotional wellness in children and adolescents. The purpose of this ’Consent to Screen’ is to ask your permission for your child to voluntarily participate in an emotional health screening. The screening is free and confidential, and the results of the screening will not be shared with the school without your consent.

Your child’s emotional wellness can affect how well they do in school, their ability to “get along” with friends and family, and their ability to bounce back when faced with life’s challenges and setbacks. Checking on your child’s emotional health is as important as having their vision and hearing tested or their yearly physical exam with your family doctor. Sometimes, it is difficult to know if your child is experiencing emotional challenges. To help you with this, Bronx Screening Program through Astor Services, is making available a simple list of questions (screening) that you and your child can complete.

The results of the screening will be assessed by an Astor team member who will let you know if a more detailed assessment of your child is recommended. The Bronx Screening Program can assist your family with being connected to resources such as local food pantries, supplemental nutrition assistance program (SNAP) benefits, supplemental security income (SSI) benefits, mental health services, behavioral health services, parent support (group & individual assistance), immigration services, educational services, low-income housing application completion support and much more to meet your family. We know from experience and science that children can and do recover from emotional challenges, particularly when they are identified early. All we need is your consent to the do the screening. If you have any questions please do not hesitate to call Tiffany Wilson, Astor SYNC/CFTSS Supervisor at 646-761-3517.

Please choose one (I understand that I have the right to revoke this “Consent to Screen” at any time.): *

I authorize Astor's Bronx Screening Program to share the screening tool as well as the results with the child’s current school program.

I do not authorize Astor’s Bronx Screening Program to share the screening tool as well as the results with my child’s current school program.

I, write name of parent/guardian: *

Give permission for my child, write first and last name of child: *

To participate in Astor’s Bronx Screening Program. (Parent/guardian electronic signature): *

Child's date of birth: *

YYYY

Your child's gender: *

Female

Male

Other:

Today's Date: *

YYYY

Address (please include the apartment number if applicable): *

City: *

State: *

Zip Code: *

Telephone Number: *

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