Please thoroughly review this document as it contains information that is very important for you to know.
A psychological evaluation is a process that includes a combination of clinical interviews, completion of written questionnaires, and use of a variety of standardized measures in two or more one-on-one appointments with you alone, with you and another person, and/or with you and your family. Depending upon your concerns and the referral questions to be answered by the evaluation, testing may include measures of:
| • Behavioral and emotional functioning |
• Problem solving strategies |
• Compliance with court order |
| • Substance use disorders |
• Intimate partner violence |
• Anger management skills |
| • Personality traits and functioning |
• Readiness to under bariatric surgery |
• Disability determination |
| • Cognitive ability |
• Academic achievement |
• Child abuse, neglect, or dependency |
| • Specific learning disorders |
• Attention and executive functioning |
• Child custody and visitation |
| • Emotional intelligence |
• Information processing skills |
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Benefits and Risks of Evaluation – The primary benefits of an evaluation include diagnostic clarification, appropriate treatment recommendations, a written report to facilitate service coordination and decision making, and insight into the nature of the person’s mental characteristics or attitude. There are some risks associated with testing. You may experience discomfort (frustration, anxiety, embarrassment, etc.). Also, it is possible that the evaluation will not answer all of your questions, and further evaluation may be needed. While the assessment and treatment recommendations are based on best practices, you or others may not agree with the conclusions based on my professional judgment. It is your decision whether to follow the recommendations.
Evaluation Process – The evaluation process takes place in four primary stages: (1) Background interview; (2) Testing or diagnostic interviews; (3) Scoring, interpretation, and report; and (4) Feedback session. During this process, it is often helpful to communicate with other professionals who have worked with or are working with you. This may include therapists, physicians, counselors, teachers, speech or occupational therapists. You will be asked to sign additional written consents if this is necessary. A comprehensive written report will be generated and shared with other involved professionals including but not limited to attorneys, healthcare providers, and social services. You must know that in advance that I will not change the presentation of the results, the diagnoses or the recommendations purely so that they meet criteria for special supports or accommodations; to do so would be unethical.
Fees and Payment - The retention fee for the background interview is $500.00. Psychological testing and assessment is time consuming and requires significant specialized training. The type and complexity of psychological evaluation to be completed determines the final fee to be paid, which may range between $1000.00 and $7000.00. This price includes the testing sessions, feedback session, and preparation of the written report. If you must cancel an appointment, please give a minimum of 24 hours advance notice or you will be charged a cancellation fee of $100 for the initial appointment or $ 200 for a testing appointment. If you are interested in submitting a request for reimbursement, please contact your insurance company to request information about out-of-network benefits for psychological consultation and testing prior to the first appointment. Any pending balance must be paid before the final report is released. Completion of brief forms and letters for justification of diagnoses, evaluation, or treatment are charged at a rate of $25. The turn-around period for completion of forms or letters is seven days. If the evaluator is required by subpoena or court order to testify in any matter related to the psychological evaluation services, you will be expected to pay ($350 per hour) for all of the professional time used, including preparation and transportation costs, even if the call is made by another party. It is your responsibility to contract with your lawyer to quash the subpoena or to sign a waiver of confidentiality if you want the subpoena not to be answered.
Confidentiality – In general, the privacy of all communications between a patient and a psychologist is protected by law. Information can only be released to others with your written permission. Exception to this law include proceedings involving custody, following a complaint or lawsuit against the evaluator, in cases where there is suspicion that a child has been subjected to abuse or neglect, if there is propensity for violence and intention to inflict imminent physical injury upon a specified victim, and when submitting claims to insurance companies.
Acknowledgement – This consent and agreement has been explained to me fully in terms that I can understand. I understand that the evaluator will primarily conduct a psychological evaluation and offer recommendations about treatment and/or other services, if necessary. I agree to help as much as I can, by supplying full answers, making an honest effort, and working as best I can to make sure that the findings are accurate. I understand the results will not be confidential if the evaluator testifies as a witness in court. I understand that this evaluation is to be done for the purposes of an examination of extreme psychological hardship, physical and/or emotional abuse, credible fear of persecution/torture, any mitigating factors that may get me a shorter sentence, my risk of criminal re-offending, or attempts I have made to malinger exaggerate or minimize disabilities.
My professional judgment gives me no reason to believe that this person is not fully competent to give informed and willing consent.