This is a strictly confidential patient medical record.
THIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
A psychological evaluation involves an assessment of intellectual functioning, processing skills, academic functioning, and social-emotional functioning. Background history and teacher input, as well as previous records, provide additional information to assist in diagnosis. Evaluations typically involve 3 to 8 hours of testing, dependent upon the referral question, 1.5 hours for a conference, and 2 to 8 hours of time to complete the written report. A final copy of the report will be provided in person or e-mailed using a password- protected .PDF format following the feedback conference. The report will be extensive and will include all scores from the testing. When the testing is scheduled, you will be expected to provide credit card information to secure your appointment time.
Our policies have changed, due to high demand and a lengthy wait list for services. As our doctors set aside a half to a full work day for your or your child’s assessment, you will be charged $300 for the appointment if you do not provide 48 hours advance notice of cancellation, unless we both agree that you were unable to attend due to circumstances beyond your control. If your testing appointment has already been rescheduled once, a $500 deposit will be required at the time of a second rescheduling that will be applied towards the testing fee. If you do not provide 48 hours advance notice of cancellation of the second testing appointment, your deposit will be forfeited. On the rare occasion when a child is non-compliant with the testing process and the testing cannot be completed, you will be expected to pay for the time spent working with your child and any additional time required to write a summary.
SUPERVISION AND TRAINING:
Some services may be provided by a psychologist licensed in an alternate state or certified as a school psychologist, who is under the direct supervision of a Licensed Psychologist. If you have any questions or concerns about working with these psychologists, please inform the psychologist and your questions will be answered or your case will be transferred to one of our Georgia licensed staff.
CONFIDENTIALITY AND RECORDS:
Your communications with me will become part of a clinical record of treatment, and it is referred to as Protected Health Information (PHI). Your PHI will be kept in a file stored in a locked cabinet, or kept electronically on an encrypted drive or HIPAA-compliant electronic storage service. Additionally, we will always keep everything you say completely confidential, with the following exceptions: (1) you direct us to tell someone else and you sign a "Release of Information" form; (2) your psychologist determines that you are a danger to yourself or to others; (3) you report information about the abuse of a child, an elderly person, or a disabled individual who may require protection; or (4) your psychologist is ordered by a judge to disclose information. In the latter case, our license does provide us with the ability to uphold what is legally termed "privileged communication." Privileged communication is your right as a client to have a confidential relationship with a psychologist. If for some unusual reason a judge were to order the disclosure of your private information, this order can be appealed. We cannot guarantee that the appeal will be sustained, but your psychologist will do everything in their power to keep what you say confidential.
In addition, you should be aware that we each practice with other mental health professionals in our office and that we have administrative staff. In most cases, we need to share protected information with these individuals for both administrative and clinical purposes such as scheduling, billing, and quality assurance. We also have a formal business associate contract that requires them to maintain confidentiality. All mental health professionals are bound by the same rules of confidentiality and all staff members and business associates have been given training about protecting privacy and will not release information without permission.
STRUCTURE AND COST OF SESSIONS:
We charge $175 per hour for many other professional services you may need, though we will break down the cost if we work for periods of less than one hour. Other services include report writing, telephone calls that exceed 15 minutes in duration, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any service you request of your psychologist. You will be expected to pay for half of a full psychological evaluation, or all of a screening evaluation on the first day of the assessment by cash, check, or credit card. We will provide you with a receipt of payment. The receipt of payment may also be used as a statement for insurance if applicable to you. There is a $25 fee for any returned check. The final half of the evaluation fee will be collected at the feedback session when results and report are received.
Insurance companies have many rules and requirements specific to certain plans. It is your responsibility to find out your insurance company's policies and to file for insurance reimbursement. We will be glad to assist you with any questions you may have in this area and to provide you with required receipts to file your claim. We do not file insurance forms directly and we cannot guarantee reimbursement through any insurance company. Please be aware that we are an out-of-network provider for all insurance companies.
If you become involved in legal proceedings that require our professional participation, you will be expected to pay for all of the psychologist’s professional time, including preparation and transportation costs, even if they are called to testify by another party. Because of the difficulty of legal involvement, our psychologists charge $350-$450 per hour for preparation and attendance at any legal proceeding.
Overdue accounts of more than 60 days are subject to late fees and may be turned over to collections to obtain payment. When accounts are turned over to collections your name, date of service, and account balance will be shared. No information related to your treatment will be revealed.
MINORS AND PARENTS:
Patients under the age of 18 who are not emancipated and their parents should be aware that the law allows parents to receive the results of the psychological evaluation. Families may decide who will attend the conference to review the test results following the evaluation, although your psychologist may have suggestions about what they feel is appropriate.
IN CASE OF AN EMERGENCY:
Our practice is considered to be an outpatient facility, and we are set up to accommodate individuals who are reasonably safe and resourceful. We are not available at all times. If at any time this does not feel like sufficient support, please inform your psychologist, and we can discuss additional resources or transfer your case to a therapist or clinic with 24-hour availability. Generally, we will return phone calls within 24-48 hours. If you have a mental health emergency, we encourage you not to wait for a call back, but to do one or more of the following:
Call Behavioral Health Link: 800-715-4225
Call Ridgeview Institute: 770.434.4567
Call Peachford Hospital: 770.455.3200
Go to your nearest emergency room
STATEMENT REGARDING ETHICS, CLIENT WELFARE & SAFETY:
We assure you that services will be rendered in a professional manner consistent with the ethical standards of the American Psychological Association. If at any time you feel that your psychologist is not performing in an ethical or professional manner, we ask that you please let the psychologist know immediately. If we are unable to resolve your concern, you have the right to complain to the U.S. Department of Health and Human Services.
In our ever-changing technological society, there are several ways we could potentially communicate and/or follow each other electronically. It is of utmost importance to us that we maintain your confidentiality, respect your boundaries, and ascertain that your relationship remains therapeutic and professional. Therefore, we have the following policies:
Cell phones: It is important for you to know that cell phones may not be completely secure and confidential. However, we realize that most people have and utilize a cell phone. We may also use a cell phone to contact you. If this is a problem, please feel free to discuss this with your clinician.
Text Messaging and Email: Both text messaging and emailing are not secure means of communication and may compromise your confidentiality. However, we realize that many people prefer to text and/or email because it is a quick way to convey information. If you choose to utilize texting or email, please sign consent for such communication below. However, please know that it is our policy to utilize these means of communication strictly for brief topics such as appointment confirmations. If you bring up any therapeutic content via text or email, you may compromise your confidentiality. You also need to know that we are required to keep a copy of all emails and texts as part of your clinical record.
Facebook, Linkedln, Instagram, Pinterest, etc: It is our policy not to accept requests from any current or former client on social networking sites such as Facebook, Instagram, Pinterest, etc. because it may compromise your confidentiality.
Google, etc.: It is our policy not to search for our clients on Google or any other search engine. We respect your privacy and make it a policy to allow you to share information about yourself with your clinician as you feel appropriate.
In summary, technology is constantly changing, and there are implications to all of the above that we may not realize at this time. Please feel free to ask questions, and know that we are open to any feelings or thoughts you have about these and other modalities of communication.
AGREEMENT TO ENTER INTO A RELATIONSHIP FOR PSYCHOLOGICAL EVALUATION:
Please print, date, and sign your name below indicating that you have read and understand the contents of this form, you agree to the policies of your relationship with your psychologist, and you are authorizing the psychologist to begin evaluation with you or your child.