Adult Neuropsychological Evaluation Informed Consent Form

NOTICE TO CLIENTS AND CONSENT TO NEUROPSYCHOLOGICAL EVALUATION AGREEMENT

Portsmouth Neuropsychology Center, LLC

501 Islington Street; Suite 1F

Portsmouth, NH 03801

Ph. (603) 433-0800

Fax (603) 297-2913

TO OUR CLIENTS:

The Board of Mental Health Practice regulations, including the Mental Health Bill of Rights, require all licensed mental health professionals to provide clients certain basic information. Also, to avoid confusion or misunderstandings, I am providing additional important information about my practice for your review and agreement. Please read it carefully and discuss any questions you have before signing below.

1. LICENSE AND CODE OF ETHICS

I am a licensed psychologist, governed by the Code of Ethics of the American Psychological Association. My license is displayed in my office. A copy of the Code of Ethics is available at all times in my office. I will provide information regarding my training, qualifications and experience at the initial meeting and upon request.

2. QUALIFICATIONS AND SCOPE OF PRACTICE

I received my Ph.D. in clinical psychology in 2011 from Stony Brook University. I received post-doctoral training in assessment at Children's Hospital Boston. My practice areas include assessment and psychotherapy with children, adolescents, and adults.

3. NEUROPSYCHOLOGICAL EVALUATIONS

As part of your evaluation, I will discuss with you my proposed plan for proceeding with the evaluation. In general, evaluations can take one to two sessions to complete, and can last several hours each session. I utilize a psychometrist to assist with test administration and scoring.

At the end of the evaluation I will assess the data to better understand your strengths and weaknesses. A feedback session will follow. You will receive a comprehensive report following complete payment for services. Once payment is received, the report is generally mailed four weeks following the feedback session. Evaluations can have benefits and risks. Some individuals experience fatigue or uncomfortable feelings such as frustration. On the other hand, the results of an evaluation can lead to a better understanding of your strengths and weaknesses and can lead to appropriate recommendations. However, there are no guarantees of what you will experience.

You should be aware that there are alternative types of services to those being offered by me. You may prefer to obtain an evaluation from someone other than me. You also have the choice not to obtain any evaluation services. There are also risks and benefits associated with alternatives and with not pursuing an evaluation. To the extent that you are interested in alternatives, you should discuss this with me. The evaluation can be stopped at any time.

4. CONFIDENTIALITY

Under New Hampshire law, communications between a client and a licensed psychologist are privileged (confidential) and may not be disclosed without the specific authorization of the client except under specific, limited circumstances. For example, the privilege does not apply in a civil commitment proceeding in which the issue is whether the individual is a danger to self or others or when a client is seeking treatment relating to a workers' compensation claim. Records may also be subject to audit by regulatory authorities. Also, many reporting laws create exceptions. See paragraph 5 below.

As part of maintaining a valid license, I am required to regularly discuss cases with colleagues. I also obtain formal supervision on certain cases when I believe it is necessary. In these situations I do not disclose the identity of my client. My colleagues and any formal supervisor are, of course, legally bound to confidentiality as well. By signing this document you are acknowledging that you understand that I may discuss your case in consultation and/or supervision and do not object to my doing so.

5. REPORTING REQUIREMENTS

Among the exceptions to confidentiality are New Hampshire reporting laws which require licensed psychologists to report to the appropriate authorities certain types of conduct. For example, any person who suspects a child or incapacitated adult has been abused, neglected or exploited must report to state authorities. Licensed psychologists are required to warn the police or likely victims of a client's "serious threat of physical violence" to a person or property. There are also other reporting laws.

6. CONFLICTS OF INTEREST

New Hampshire is a small state. From time to time, actual or potential conflicts of interest may arise. In the event that I become aware of a conflict of interest in providing treatment to you, I may be required to refer you to another psychologist. Regardless of the existence of a conflict of interest, you can be assured that any information will remain confidential.

7. COURT ORDERED TREATMENT

If you are seeing me due to a court order requiring you to seek an evaluation, it is my policy that we not proceed with the evaluation until I have received a copy of the court order and have had an opportunity to review it. Because you have been ordered by the court to obtain an evaluation, there are limits on confidentiality in addition to the ones described in paragraph 5 entitled Confidentiality. For example, I may be obligated to file a report with the court that ordered you to seek an evaluation or with someone else.

8. PROFESSIONAL BOUNDARIES

Licensed psychologists are obligated to establish and maintain appropriate professional boundaries (relationships) with present or past clients (and, in some cases, client's family members). For example, psychologists should not socialize or become friends with clients and should never become sexually involved with a client.

9. COST OF PROFESSIONAL SERVICES

The cost of a neuropsychological evaluation is $4500 billed by flat fee. Payments are made in three installments. An initial deposit of $500 is due within 24 hours of booking on our online deposit site. Once paid, your deposit is NOT refundable unless you provide our office at least 10 business days of advance notice prior to your appointment. To cancel your appointment, you must call our office at (603) 433-0800. A second payment of $2000 is due at intake and the final payment of $2000 is due by the last testing session. The last two payments can be made by cash or check payable to “Portsmouth Neuropsychology Center.” After I receive your complete payment, I will meet with you for the feedback session. I will write the report and send it to you by mail. All payments must be received before the feedback session can be scheduled.

If a determination is made at the initial intake meeting not to proceed with the evaluation for any reason, the fee for that intake is $225 and the remainder of your deposit will be refunded.

Portsmouth Neuropsychology Center works as an out-of-network provider and therefore does not participate directly with insurance plans. I am willing to help facilitate any reimbursement potential you are eligible for from your insurance company (e.g,. completing forms, making phone calls).

10. LIMITS OF SERVICES

Unless specifically agreed to otherwise, my role is to provide neuropsychological evaluation services, not to assess fitness for custody, serve as an advocate on other issues or act as an expert witness.

11. CHARGES FOR ADDITIONAL SERVICES

In the event I am requested or required by subpoena to provide ancillary forensic professional services relating to my role as your evaluator, such as preparing an evaluation summary, report writing, phone calls/meetings, deposition or trial preparation and attendance, you agree to compensate me according to the following rates:

$400/hour

Record review, preparation time, telephone calls, and in-person conferences for any legal contexts, including but not limited to depositions and hearing. Charges are calculated in 15 minute increments and payment is required within 30 days of receiving the invoice.

$4,000/day

Deposition and courtroom testimony. Please note that this fee also applies if I am subpoenaed or receive a court order to provide testimony. Payment for deposition and/or courtroom testimony must be made 72 hours in advance of the offering of such testimony and is entirely non-refundable.

PNC also bills separately for out-of-pocket forensic expenses, such as travel expenses, mileage, overnight delivery, copies, etc.

12. LIMITS OF AVAILABILITY AND PROVISIONS FOR EMERGENCY COVERAGE

In the event of an emergency, you can reach me at (603) 433-0800. If I am unavailable, you can leave a message on my voice mail and I will return your phone call as soon as possible. Phone calls are not checked after 5pm during the weekday. Please note that calls received after 12pm on Friday may not be returned until the following Monday.

13. PROFESSIONAL RECORDS

I maintain a file for each client or set of clients. This includes intake, test forms, report, diagnosis (if applicable), billing records, consent to treatment, and any other written or electronic information I received from or about the client.

14. ELECTRONIC COMMUNICATIONS

I do not respond to electronic communications (e.g., e-mail, texts) from you regarding your evaluation. My office manager utilizes e-mail for scheduling and billing.

ACKNOWLEDGEMENT AND ACCEPTANCE

Client Name: Date of Birth:

I authorize Dr. Lauren Cook to perform a neuropsychological evaluation for myself.

I understand that no promises have been made to me as to the results of this assessment.

I am aware that I may stop the assessment at any time but will still be responsible for payment for services rendered.

I am aware that I am responsible for any information provided to the insurance company and that Portsmouth Neuropsychology Center does not participate in insurance plans.

My signature below shows that I understand and agree with all of these statements.

I, the clinician, have discussed the issues above with the client (or other representative). My observations of this client’s behavior and responses give me no reason to believe that this client is not fully competent to give informed and willing consent.