Healthcare Psychological Evaluation Consent

HEALTHCARE PSYCHOLOGICAL EVALUATION CONSENT

Patient Information

Date of Birth:    Gender: Male Female Non-binary Prefer not to say Other:

Primary Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Subscriber Relationship to Patient:

Medical & Mental Health History

Consent for Psychological Evaluation

I authorize the clinician to perform a comprehensive psychological evaluation to assess cognitive, emotional, behavioral, and psychosocial functioning. The evaluation may include clinical interview, standardized psychological testing, self-report inventories, behavioral observations, review of medical and educational records, and collateral interviews with the patient's consent. Specific procedures may include:

Clinical interview
Standardized cognitive and achievement testing
Personality inventories and symptom measures
Neuropsychological testing (if indicated)
Collateral interviews (family, caregivers, educational personnel)
Review of medical, educational, or employment records

Risks, Benefits & Alternatives

Potential benefits: improved diagnostic clarity, identification of strengths and needs, treatment planning recommendations, and information useful for accommodation or service eligibility. Potential risks: temporary emotional distress when discussing sensitive topics, fatigue from testing, or identification of diagnoses that may carry stigma. Alternatives include declining evaluation or seeking evaluation from another qualified provider. Refusal to consent will not affect eligibility for other services, except where assessment is necessary for specific service determination.

Confidentiality & Limits

Information obtained during the evaluation is confidential and will be disclosed only with written authorization except in the following circumstances as required or permitted by law: imminent risk of serious harm to self or others, suspected abuse or neglect of a child, dependent adult, or elderly person, compliance with a lawful court order or subpoena, or as necessary for billing and coordination of care. Test protocols and certain raw test data may be considered part of the clinician's professional records and may be retained by the provider.

Recording, Release of Results, and Use of Records

I consent to: Audio recording Video recording No recording

Authorization expiration date: . If no date is provided, this authorization expires one year from the date signed.

Voluntary Consent & Right to Withdraw

I have been informed of the nature and purpose of the psychological evaluation, the procedures to be used, the potential risks and benefits, and the limits of confidentiality. I understand that I may ask questions at any time and may withdraw my consent for testing or release of information, except to the extent that action has already been taken in reliance on this consent. Withdrawal of consent may limit the clinician's ability to complete the requested evaluation or provide conclusions based on incomplete data.

I acknowledge that no guarantees have been made to me regarding the results of the evaluation. I understand that evaluation reports, summaries, and recommendations are the intellectual property of the clinician and may be released only pursuant to my authorization or as otherwise permitted by law.

HIPAA / Privacy Notice Acknowledgment

By signing below I acknowledge that I have been offered or received a copy of the provider's privacy practices and understand how my protected health information may be used and disclosed in connection with this evaluation and related services.

I acknowledge: I acknowledge receipt of privacy practices.

Patient Certification

By signing below, I certify that I am the patient named above or the legal guardian or authorized representative of the patient. I have read this consent (or it has been read to me), all of my questions have been answered, and I request and consent to the psychological evaluation as described above. I authorize clinicians to communicate with the persons/agencies listed for the purposes stated above.

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