Psychological Assessment Report

Psychological Assessment Report and Services Agreement

Administrative Information

Client Name:   Date of Birth:

License / Credentials:   Organization:

Recitals

WHEREAS, Client Name: has requested a comprehensive psychological assessment to inform diagnostic clarification, treatment planning, or administrative decision-making; and

WHEREAS, Assessor Name: holds the professional credentials and licensure necessary to perform psychological assessment services and agrees to provide such services in accordance with applicable professional standards; and

WHEREAS, the parties desire to set forth the scope, payment terms, confidentiality obligations, and other terms governing the assessment process and the delivery of the written report below.

Scope of Work

The Assessor will conduct a psychological evaluation as described below, which may include clinical interview, standardized testing, behavior observation, record review, and collateral interviews. The final report will summarize findings, diagnostic impressions, and recommendations.

Instruments Administered (check all that apply)

WAIS / Adult Cognitive Battery    WISC / Child Cognitive Battery    Mental Status Exam    MMPI / Personality Inventory

Beck Depression Inventory    ADHD Rating Scales    Other:

Behavioral Observations and Test Performance

Results and Scores

Full Scale IQ:   Verbal:   Performance:

Relevant Normed Scores / Percentiles and Interpretation:

Clinical Impressions and Diagnoses

Recommendations and Treatment Plan

Payment Terms

Total Fee for Services: $

Late Payment Penalty:   Unpaid balances may accrue interest and collection costs as set forth above.

Term and Termination

Commencement Date:   Expected Completion Date:

Either party may terminate this engagement for material breach or upon written notice. Notice Period (days):

Upon termination, the Assessor will invoice for all work performed through the termination date. Client remains responsible for payment of completed services.

Confidentiality and Records

All records, test data, notes, and written reports created by the Assessor are the professional records of the Assessor. Unless otherwise required by law, the Assessor will not disclose protected health information without written authorization. Exceptions include imminent risk of harm, court order, mandated reporting, or other legal obligations.

Client may request release of records; such release shall be provided in accordance with applicable law and within a reasonable timeframe upon receipt of a signed release specifying recipient and purpose.

Consent and Authorization

By signing below, Client consents to the assessment process described herein, authorizes necessary collateral contacts, and acknowledges understanding of fees, confidentiality limits, and the scope of services. Client also acknowledges receipt of a copy of this report and agreement.

Client Consent: I consent to the assessment and release of necessary information as described above.

Governing Law; Entire Agreement

This Agreement and any disputes arising out of the assessment or this report shall be governed by the laws of the state selected by the Assessor and Client at the time of execution. This document, together with any attached test data or addenda, constitutes the entire agreement between the parties with respect to the assessment and supersedes all prior understandings, whether written or oral.

Limitations and Use of Report

This report is prepared for use by the Client and authorized recipients and is not intended for broad distribution. The Assessor disclaims responsibility for decisions made solely on the basis of this report without appropriate clinical consultation or follow-up.

Attachments and Addenda

Any supplemental material, raw test scores, or collateral reports attached to this document are incorporated by reference and form part of this Agreement and final report.

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