CONSENT FOR PSYCHOLOGICAL/PSYCHO-EDUCATIONAL TESTING

Welcome toRittenhouse Psychological Assessments, LLC . This document contains important information about our professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.

Nature and Purpose of Assessment: Psychological/Psychoeducational assessment includes a comprehensive evaluation of you or your child’s intellectual, academic, and/or emotional functioning. The evaluation will require direct contact, interviewing, and testing. The review of relevant records and information from schools, psychologists, physicians, and other professionals involved is often necessary to ensure a comprehensive and valid assessment. A psychological assessment seeks to provide information about a specific question pertaining to psychological, cognitive, or emotional functioning, using standardized and empirically validated tools chosen by the evaluator. The results can be of great value in accessing specialized services, qualifying for educational or occupational accommodations, clarifying the nature of emotional or cognitive symptoms, and designing treatment interventions. Before testing begins, your evaluator will explain the details of each type of testing, the process, and the method for providing results to you. Our practice offers a wide variety of psychodiagnostic services.

Foreseeable Risks and Discomforts: For some individuals, assessments can cause fatigue, frustration, and anxiety. A comprehensive clinical interview may include questions that evoke feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Further, undergoing a psychological assessment may involve discussing unpleasant aspects of your life and may lead to unanticipated results and/or conclusions you find to be discomforting. Rittenhouse Psychological Assessments, LLC attempts to minimize these risks by thoroughly reviewing the nature and purpose of the testing with you, providing well-trained clinicians and explaining the results in language you can understand.

If you or your child is undergoing testing as part of a disability claim or requesting accommodations from your child’s school or a standardized testing company (e.g., Educational Testing Service, College Board), it is important to remember that the test results obtained from the assessment may not support you or your child’s claim and may even cause the request to be denied.

Fees and Time Commitment: The standard hourly fee for the assessment is $125 per hour and total assessment costs are based on this rate. The testing fee includes time spent on the intake interview, test administration, scoring, interpretation, report writing, consultation with other professionals involved in the case, and feedback. The total time involved for a full evaluation, report, and feedback varies based upon the referral question.

The total fee will be discussed prior to initiating testing. 50% of the anticipated fee is due prior to testing and the remaining fee will be due upon completion of the report. Patients are responsible for any and all fees for the assessment regardless of the final diagnosis, invalid test data, or possible results of test data.

Most insurance companies do not cover the cost of testing for psychological and/or educational purposes.

Please be aware that Psychoeducational Evaluation for the purpose of determining eligibility for placement in special education is available at no cost to you through your local school district. Because most insurance providers do NOT cover the cost of testing for educational purposes, we strongly suggest that you contact your insurance provider before your start any testing, referring to CPT Code 96101, to learn about benefits and precertification or preauthorization requirements. We cannot speak for your insurance company. We are glad to provide you with an itemized receipt suitable for insurance submission. Also, we cannot alter an accurate diagnosis to suit the requirements of insurance providers.

CONFIDENTIALITY AND PRIVACY OF INFORMATION

Your evaluator will make every effort to safeguard the privacy of information concerning your work together. It is a violation of the law, as well as the Ethical Principles of the American Psychological Association, to disclose any information regarding the treatment of clients. For information to be disclosed to individuals outside ofRittenhouse Psychological Assessments, written consent from you must be provided.

There are several specific exceptions to the rules of confidentiality. These are listed below:

• You may authorize your clinician to release records or other information to individuals of your choosing. Your clinician may only do this with your expressed written consent.

• Under ethical and legal requirements, your clinician may be required to break confidentiality in the event of a clear and imminent danger to yourself or another person.

• In the event that you disclose information that provides evidence of current abuse or neglect of minor children or a vulnerable adult, the law requires that your clinician make a report to the appropriate state agency.

• In certain legal proceedings, confidential information may be disclosed by court order. This is a rare occurrence and would not happen without your knowledge.

• If full payments are not made for work conducted, your name and contact information as a client of Rittenhouse Psychological Assessments, LLC will be given to a credit collection agency.

CONTACTING YOUR EVALUATOR

Due to the nature of the work, psychologists are often not immediately available by telephone. When unavailable, their telephone is answered by voice mail. We check our messages regularly and will make every effort to return your call within 24 hours, with the exception of weekends and holidays. Our voicemail is confidential. If you are unable to reach your clinician, and in the case of an emergency you feel that you are unable to wait for someone to return your call, contact your family physician, the nearest emergency room, or call 911.

USE OF E-MAIL

Your evaluator may provide you the opportunity for you to communicate with him or her by e-mail. Transmitting confidential client information by e-mail, however, has a number of risks, both general and specific, that you should consider. General e-mail risks include: E-mail may be received by many intended and unintended recipients, recipients can forward e-mail messages to other recipients without the original sender's permission or knowledge, users can easily misaddress an e-mail, e-mail is easier to falsify than handwritten or signed documents, and backup copies of e-mail may exist even after the sender or recipient has deleted his or her copy.

Specific client e-mail risks include: Employees do not have an expectation of privacy in e-mail they send or receive at their place of employment and clients who send or receive e-mail from their place of employment risk having their employer read their email; clients have no way of anticipating how soon their evaluator will respond to a particular e-mail; although we try to read and respond to e-mail promptly, we cannot guarantee that any particular message will be read and responded to within any particular period of time.

Conditions for the Use of E-mail:

It is the policy ofRittenhouse Psychological Assessments, LLC, that we will treat all e-mail messages that concern the client with the same degree of confidentiality as afforded other portions of the medical record. We will use reasonable means to protect the security and confidentiality of e-mail information but are not liable for improper disclosure of confidential information not caused by our gross negligence or misconduct. Additionally, because of the risks outlined above, we cannot guarantee the security and confidentiality of e-mail communication. Thus, clients must consent to the use of e-mail for confidential medical information after having been informed of the above risks. Finally, clients must not use e-mail in a medical or psychiatric emergency.

CANCELLATION POLICY

Once an appointment hour is scheduled and is cancelled without 24 hours notice a $185.00 late cancellation fee will be charged to your account. We realize that situations arise that can make late cancellations or missed appointments unavoidable. Though we understand that issues come up at the last minute, we also expect reimbursement for time that has been reserved for you. We hope you understand and appreciate this policy. It is important to note that insurance companies do not provide reimbursement for cancelled sessions.

ACKNOWLEDGMENT

Your signature below indicates that you have read the information in Rittenhouse Psychological Assessments, LLC “Consent for psychological/psycho-educational testing” and agree to abide by all its terms during our professional relationship.

Name of Client: ______

Signature of Client: ______Date: ______

If minor, Parent/Guardian's Signature: ______Date: ______

Relationship to Client: ______

Signature of Evaluator: ______Date: ______