MPS: Milwaukee Public Schools



0-189230Milwaukee Public SchoolsEducational WraparoundInformed Consent00Milwaukee Public SchoolsEducational WraparoundInformed Consent Name of Student: ______________________________________________School: ________________________School Phone: ___________________Student ID: __________________Dear Parent/ Guardian of Student First Name Student Last NameHere at School Name, we are implementing a Tier 3 PBIS (Positive Behavioral Interventions and Supports) intervention for students called Educational Wraparound. Educational Wraparound is a school teaming process for students who struggle with meeting school expectations, and might benefit from individualized attention. As part of the process, a team will work together to develop a plan of individual supports and strategies for success for Student First Name. You may have attended many meetings before at your child’s school. Educational Wraparound is different because it is based on the principle of Family Voice and Choice and this sets it apart.Educational Wraparound is completely voluntary for your family. A cornerstone of this process is that your family is the major stakeholder in decision-making. You may withdraw from the process at any point, for any reason. Team members for Educational Wraparound may include a classroom teacher, administrator, school counselor, school social worker, school psychologist, special education teacher, academic specialist(s), or other school staff who work with Student First Name. You are welcome and encouraged to include important family members and community professionals who work with Student First Name. Your family makes the decision regarding who is on the team.To begin the Wraparound process, a member of the school staff will request to meet with you on one or more occasions to have a conversation about your family and to complete an interview. Your student’s teacher will also be interviewed. These interviews will focus on gathering perspectives related to your student’s strengths and needs. Additionally, your student may be interviewed and/or observed in multiple settings at school to better understand his/her behavior. This information will then be utilized by your team to develop a plan of support. The benefits that may be achieved from involvement in the Educational Wraparound process might include, but are not limited to: improved educational, behavioral, and emotional outcomes for your student/family. Progress monitoring is a core aspect of the process, and you will be regularly notified regarding your student’s performance.TIME INVOLVEMENT: Initial meetings/interview with Wraparound facilitator from your child’s school.Meetings of the Wraparound team, which will be scheduled by your facilitator and yourself to be convenient for yourself as well as other team members. Meetings only take place with parent involvement.CONSENT RIGHTS: If you have read this form and have decided to participate in this process, please understand that your participation is voluntary and you have the right to withdraw your consent or discontinue participation at any time. You have the right to refuse to answer particular questions. Your individual privacy and the privacy of your student/family will be maintained at all times.Contact Information:The facilitator for this process with your family is:Name: _________________________________________Position: _______________________________________Phone: _________________________________________Please contact the facilitator with any concerns or questions. I give my consent to services for _____________________________________________Student’s Nameto receive support through Educational Wraparound services.I DO NOT give my consent for _______________________________________________Student’s Nameto receive support through Educational Wraparound services.__________________________________________________________________Signature of Parent / Guardian Phone ______________________Date ................
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