Casey Psychological Services
Emily Casey, Psy.D. | Licensed Clinical Psychologist
16 Wall Street | Colchester, CT 06415
860.908.9497 |
Consent and Agreement for Psychological Testing and Evaluation
I, ______, agree to allow Emily Casey, Psy.D. to perform the following services:
❑ Psychological testing/assessment/evaluation
❑ Report writing
❑ Consultation with school personnel
❑ Consultation with lawyers
❑ Deposition (written or oral testimony given to a court, but not made in open court)
❑ Testimony in court
❑ Other (describe): ______
This agreement concerns ❑ myself or ❑ ______.
I understand that this evaluation is to be done for the purpose(s) of: ______
______
______
I understand that these services may include direct, face-to-face contact, interviewing, observation and/or testing. They may also include the psychologist’s time required for review of records, consultation with other psychologists and professionals, scoring of tests, interpreting the results, and any other activities to support these services. If I have questions or concerns about this assessment, the evaluator agrees to be available to discuss these after the completion of the testing and interviews. I understand and agree that no therapist-client relationship exists or will be created between the person being evaluated and the evaluator.
I understand that the fee for this psychological testing/evaluation service will be $______, and that this is payable in two parts: a deposit of $ ______payable before the start of this (these) service(s), and a second payment of the balance due on the completion and delivery of the report (or, for depositions, testimony, or other services, at the time these services take place). I understand that I am fully responsible for payment for these services. I may request that Emily Casey, Psy.D. attend school meetings or collaborate with other providers (psychiatrists, psychotherapists, occupational therapists, teachers, or other professionals). Emily Casey, Psy.D. will only do so with my signed consent. I understand that the hourly rate of $125 per hour will be charged for conversations/collaborations beyond the initial assessment agreement as outlined above.
I understand that if my account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, Emily Casey, Psy.D. has the option of using legal means to secure payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information released regarding the services is the name, nature of services provided, and the amount due.
Emily Casey, Psy.D. does not accept insurance but, if requested, will provide the information necessary to submit claims to my insurance provider on my own. I understand that I am (not my insurance company) responsible for full payment of services rendered on the aforementioned pay schedule.
Cancellation Policy – All appointment cancellations must be made at least 24 hours in advance of the scheduled session. If I do not call to cancel and/or fail to show, I will be charged $300 for that appointment.
I also understand that Emily Casey, Psy.D. agrees to the following:
1. The procedures for selecting, giving, and scoring the tests, interpreting the results, and maintaining my privacy will be carried out in accord with the rules and guidelines of the American Psychological Association and with the applicable state and federal laws.
2. Tests will be chosen that are suitable for the purposes described above. These tests will be given and scored according to the instructions in the tests’ manuals, so that valid scores will be obtained. These scores will be interpreted according to scientific findings and guidelines from the scientific and professional literature.
3. Tests and test results will be kept in a secure place to maintain their confidentiality.
4. The report of the findings of this assessment will be sent to ______
______.
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 have read, understand, and agree to the information above. I understand my responsibility for the payment of my account. A photocopy of this document is considered to be as valid as the original.
______Signature of Client Date
______Signature of Parent/Guardian Date
I, Emily Casey, Psy.D., have discussed the issues above with the client (and/or his or her parent or guardian). My observations of this person’s behavior and responses give me no reason, in my professional judgment, to believe that this person is not fully competent to give informed and willing consent.
______Signature of Emily Casey, Psy.D. | Clinical Psychologist Date
❑ Copy accepted by client/parent/guardian ❑ Copy kept by psychologist
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
FORM 18. Consent form and contract for psychological testing and evaluation. Adapted from a form devised by John M. Smothers, PhD, ABPP, of Bethesda, MD, and used by permission of Dr. Smothers.—From The Paper Office. Casey Psychological Services (Revised 1/6/13)