Spencer Psychology

Assessment Contract and Consent

Consent

I, the undersigned, agree and consent for myself (or my minor child) to participate in the assessment offered by the staff of Spencer Psychology. I understand that I am consenting and agreeing only to those mental health services or evaluation that the provider is qualified to provide within the scope of the provider/supervisor’s license, certification, and training.

I understand that Spencer Psychology is a group practice, and consultation and supervision occur within the group. I consent to these discussions about my care. I understand the process and expectations of participating in an evaluation, and agree to proceed.

Testing Data

Raw test data cannot be released, as this would compromise test security, and is considered a breach of ethical guidelines for psychologists. Raw test data can only be released to another psychologist.

Early Termination of Evaluation

Full payment for evaluation services is non-refundable once testing has started. If you cancel a scheduled appointment, you will be offered the next available testing appointment which could be an additional wait time of several weeks. Partial reports or rough drafts are not released, as these may be inaccurate and could cause harm if conclusions are drawn based on unfinished work. However, educational testing composite scores if completed, such as finished IQ or Achievement composite scores, can be released without a report if needed.

Confidentiality

In general, the privacy of all communications between a client and a mental health provider is protected by law. Information can only be released with your permission. There are exceptions to this. There are some situations in which a provider is legally obligated to take action to protect others from harm, and confidential information about you can be released. For example, if there is information that a child, elderly person, or disabled person is being abused or neglected, a report is made with the appropriate state agency. If a client is threatening serious bodily harm to another, protective action must be taken. These actions may include notifying the potential victim (a “duty to warn”), contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself/herself, or through significant mental health symptoms is at risk to harm himself/herself, the provider may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. In most legal proceedings, the client has the right to prevent the provider from releasing information about treatment. However, if the provider receives a court order from a judge (not just a subpoena from an attorney), the records or information must be released.

Fees




Client Name:  

Electronic Signature of Client/Parent/Guardian:  

Date: