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Fullana Learning Center, Early Childhood Education Program

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Fullana Learning Center, Early Childhood Education Program





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Fullana Learning Center, Early Childhood Education Program 

 

220 North Grant Avenue  • Fort Collins, CO 80521  •  (970) 490-3204 

 

 

 

Poudre School District 

Early Childhood Education Program 

Mental Health Services Consent Form 

 

 

Dear Parent/Guardian, 

 

The staff of Early Childhood Education Program works collaboratively with students, 

parents, schools and community resources to assist students in achieving their full 

potential.  Early Childhood Mental Health Services can be essential in promoting 

positive social and emotional development, enhancing learning, and providing 

preventive strategies and crisis intervention.  Services also blend school resources with 

community resources to develop comprehensive approaches to serving students and 

their families. 

 

Typically, a Poudre School District staff member or an Early Childhood family member 

will make a referral to the Early Childhood Mental Health Services. Early Childhood 

Mental Health Specialists serve all families enrolled in the Early Childhood Program. 

The Mental Health Specialist will develop a plan to best serve your child and your 

family. This plan may include a phone consultation, home visits, short-term 

interventions, or a carefully considered referral to an appropriate community service 

agency. The Mental Health Specialist works collaboratively with you and appropriate 

school personnel to ensure quality of service and care for children and families. 

 

Please review and sign the following consent form. If you have any questions, please 

contact Corinne Van Dyke, Assistant Director of Early Childhood Education at 

cvandyke@psdschools.org

 or 970.490.3052.  

 

 


 

 

 

 

Early Childhood Program 

220 North Grant Avenue 

Fort Collins, CO 80521 

970-490-3204 

 

 

 

 

Early Childhood Mental Health Services

 

 

 

August 2015 

Student name:  

 

Student Date of Birth:  

 

School/Center/Family Mentor Name:  

 

 

 

Parent Name:  

 

      Parent Phone No.:  

 

Parent Email:  

 

Consent 

I hereby grant permission for my child and family, named above, to participate in the following 

services provided by Early Childhood Mental Health Services: 

 

 

Individual Intervention Sessions 

Family Intervention Sessions 

 

Other:   

 

and hereby release and hold harmless the Poudre School District R-1 and its board members, employees 

and agents from any and all liability, claims, causes of action, damages and demands of any kind 

whatsoever (except willful and wanton acts or omissions) that may be brought by my child or on my 

child’s behalf for any and all damages, including personal injury to my child, arising out of or in 

connection with my child’s participation in the services and associated activities.  

 

 

 

 

 

Signature of Parent/Legal Guardian 

Date 

 

Print Name:   

 

 

 

 

 

 

 

Signature of Parent/Legal Guardian 

Date 

 

Print Name:   

 

 

Non-Consent 

I hereby do not grant permission for my child named above to participate in the services noted above.  

 

 

 

 

 

Signature of Parent/Legal Guardian 

Date 

 

Print Name:   

 

 

 

 

 

 

 

Signature of Parent/Legal Guardian 

Date 

 

Print Name:   

 



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