Family Assessment Form (Decline) Family Assessment (Decline) Child's Name * Full Name Child's Date of Birth * MM-DD-YYYY format Family Assessment (Decline) This Family Assessment is designed to determine the resources, priorities and concerns of a family as it relates to the enhancement of the child’s development. The Family assessment is voluntary and must be offered as a component of an Initial Early Intervention (EI) Evaluation. Should you choose not to participate in the process, it shall in no way impact on the determination of your child’s eligibility to receive EI services. If it is your choice to decline this opportunity, please place a check-mark in the space provided directly below. Please read. Check to decline Family Assessment * I decline the opportunity to participate in the Family Assessment. Parent Signature (typed text digital signature) * Date * MM-DD-YYYY format Submit If you are human, leave this field blank.