I (client/guardian/representative referred to as the “client” throughout this notice) understand that I/we may have been referred for an examination by an agency for a consultation which may include a diagnostic assessment to assist an agency (e.g., DDD/QTC/VR/APD/FPL/legal entity) or any other referring agency, and information shared with our office will be relayed to the referring agency in a report and not to the client unless otherwise specified).
Surveillance cameras may be used by us to deter crime and ensure the safety and security of staff and persons served. Surveillance cameras will be used in common areas and/or testing rooms and conference rooms but will not include audio. Images obtained will be retained until felt otherwise by the administration. If such images have historical value or are used for criminal investigation, their storage may be extended. Everyone is prohibited from using recording devices (pictures, audio/video) to record tests, interviews, or any interactions without the written consent of this office (only Dr. Zaky can authorize). It is strictly prohibited to post any business conducted before, during, or after the consultation on social media and in all forms.
I (client) understand and agree that the referring agency/insurer (if any) is often responsible for payment (unless you are told otherwise) for services provided by our office. However, suppose you fail to voluntarily cooperate with the evaluation process by rescinding or discontinuing your consent to release your final report to the referral agency/insurer. In that case, you (the client) will be responsible for the total fees for services rendered. FEES ARE NON-REFUNDABLE. I (client) understand that due to the nature of the services, no doctor-patient relationship would exist, and if the client wishes to obtain a copy of their report or has question(s) about the conclusions, the client must contact the referring agency/entity directly as no report(s) or disclosures will be provided by the doctor/staff directly to the client. I (client) understand that if there is a perception of imminent danger of harming self/others/abuse/neglect, then the doctor/staff must inform the authorities/agencies to pursue involuntary commitment/Baker Act to protect the person served/others.
I (client) understand the conditions above and agree to proceed with services that may include psychological testing such as IQ testing, learning disability, memory testing, personality, etc. I (client) understand that Dr. Zaky and/or his staff do not have the authority to make any final determination (i.e., approval/denial) in cases of SSDI benefits or any benefits/services the client may be applying for.
INFORMED CONSENT FOR CONSULTATIVE EXAMINATION VIA VIDEOCONFERENCE: Before starting the examination, you (client) agree to the following: There are potential benefits and risks of video-conferencing – e.g., limits to confidentiality (risk of computer/network hacking), inability to obtain as much information as in a face-to-face interview – that differ from in-person sessions. Confidentiality applies to telepsychology services; nobody will record encounters without permission from the other person(s). We agree to use the video-conferencing platform selected for the evaluation. Please use a webcam or smartphone during the session. During the session, it is essential to be in a quiet, private space free of distractions (including a cell phone or other devices). A secure internet connection rather than public/free Wi-Fi is highly recommended. We need a backup plan (e.g., a phone number where you can be reached) to restart the session or reschedule it in the event of technical problems. We need a safety plan that includes at least one emergency contact and the closest ER to your location in the event of a crisis. As the examiner, I may determine that telepsychology is no longer appropriate due to certain circumstances and that we should consider other options as preferred by your referring agency (if any).