INFORMED CONSENT FOR A PSYCHOLOGICAL EVALUATION

While the parents can expect benefits from this evaluation for the child, they fully understand that no particular outcome can be guaranteed. The parents understand that they are free to discontinue treatment of the child at any time but that it would be best to discuss with the psychologist any plans to terminate the evaluation before doing SO.

The parents have fully discussed with the psychologist what is involved in a psychological evaluation and understand and agree to the policies about scheduling, fees and missed appointments. The discussion of the evaluation process has included the evaluation procedures, diagnostic formulation of the child's problems, and information about record-keeping. The parents have been informed about and understand the extent of an evaluation, its foreseeable benefits and risks, and possible alternative methods of treatment.

The primary benefits of an evaluation include diagnostic clarification, appropriate treatment recommendations to identify challenges and maximize strengths, a written report to facilitate services in the community or school, and insight into the nature of the child's strengths and weaknesses. Although most individuals have a positive experience during the evaluation process, there are some risks. The person being evaluated may experience discomfort (frustration, anxiety, embarrassment, etc It is also possible that the evaluation will not answer all of your questions, and further evaluation may be needed. While the assessment and treatment recommendations are based on best practices, you or others may not agree with the conclusions based on Dr. Cometti's professional judgement. It is your decision to follow the recommendations.

The parents understand that the psychologist does not provide emergency service. The psychologist has told the parents whom to call if an emergency arises and the psychologist is unavailable. The parents have access to a copy of this form and a HIPAA Notice of Privacy Practices on Pediatric Advanced Therapy website (www.patkids.com A copy can be provided if the parents do not have access to the internet. The parents understand that information about the evaluation report is almost always kept confidential by the psychologist and not revealed to others besides the parents unless a parent authorizes such release. There are a few exceptions as noted in the HIPAA Notice of Privacy Practices. Details about certain of those exceptions follow:

1. The psychologist is required by law to report suspected child abuse or neglect to the proper authorities.
2. If a child tells the psychologist that he or she intends to harm another person, the psychologist must try to protect the endangered person, including by telling the police, the person and other health care providers. Similarly, if a child threatens to harm him or herself, or a child's life or health is in any immediate danger, the psychologist will try to protect the child, including, as necessary, by telling the police and other health care providers, who may be able to assist in protecting the child.
3. If a child is involved in certain court proceedings the psychologist may be required by law to reveal information about the child's treatment. These situations include child custody disputes, cases where a patient's psychological condition is an issue, lawsuits or formal complaints against the psychotherapist, civil commitment hearings, and court-ordered treatment.
4. If the parents' and child's health insurance or managed care plan will be reimbursing or paying the psychologist directly, they will require that confidentiality be waived and that the psychologist give them information about the child's treatment.
5. The psychologist may consult with other healthcare professionals about the child's treatment, but in doing SO will not reveal the child's name or other information that would identify the child unless specific consent to do SO is obtained from a parent. Further, when the psychologist is away or unavailable, a psychotherapist might answer calls and SO will need to have access to information about the child's treatment.
6. If an account with the psychologist becomes overdue and responsible parties do not work out a payment plan, the psychologist will have to reveal a limited amount of information about a patient's treatment in taking legal measures to be paid. This would include the child's and parents' names, social security number, address, dates and type of treatment and the amount due.

In all of the situations described above, the psychologist will try to discuss the situation with a parent before any confidential information is revealed and will reveal only the least amount of information that is necessary.

The parents, as legal guardians of the child, have rights to general information about what takes place in the child's evaluation session, to information about any dangers the child might present to self or others, and, upon request, to obtain copies of the child's evaluation report (with certain qualifications and exceptions The parents understand that it is usually best not to ask for specific information about what was said in evaluation sessions because this might break the trust between the child and the psychologist, especially for children over the age of 12.

The parent(s) agree that in the event custody of, or visitation with, the child is contested in a legal proceeding, each of the parents and their attorneys will not require the psychologist to testify at any of the proceedings. The psychologist's role is diagnostic in nature, and because of this, other forensic professionals would be better able and more appropriate to conduct this type of evaluation. Because of these limitations, the psychologist also will not give any opinion regarding custody, visitation, or any other legal issue. If such a proceeding does occur, the parent(s) agrees that the psychologist's role will be limited to providing a mental health professional appointed to perform such an evaluation, and/or to the attorneys, law guardian, if any, and the judge involved in the legal proceeding, written information regarding, and/or the record of, the child's treatment; the psychologist will provide these either as required by law or upon the authorization of either parent.

If the parent(s) and child are participating in a managed care plan, the parents have discussed with the psychologist their financial responsibility for co-payments, and the plan's limits on the number of therapy sessions. If the parents are not participating in a managed care program, they understand that they are fully financially responsible for treatment, including any portion of the fees not reimbursed by health insurance. The psychologist has also discussed options for continuation of treatment when managed care or health insurance benefits end.

The parents understand that they have a right to ask the psychologist about the psychologist's training and qualifications and about where to file complaints about the psychologist's professional conduct.

By signing below the parent(s) is indicating that they have read and understood this agreement, that they give consent to the psychologist for a psychological evaluation of the child, and that they have the proper legal status to give consent for a psychological evaluation for the child.

Assumption of Risk
I acknowledge that there is some risk inherent in the use of the therapy equipment where my child may take a break from testing activities, or where the psychologist may gather informal supporting data, and I agree to assume such risk and indemnify and hold Pediatric Advanced Therapy and its staff, harmless from any and all losses and claims for any injuries or other damages occurring to myself, my child or our belongings.

Psychological Testing Telehealth Informed Consent

The main venue for my psychotherapy treatment will be Pediatric Advanced Therapy office in Matthews, NC. I understand that telehealth includes the practice of health care delivery, including mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, and/or data communications. I understand that telehealth also involves the communication of my medical/mental health information, both orally and visually, to other health care practitioners. I understand that I have the following rights with respect to telehealth:

(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
(2) The laws that protect the confidentiality of my medical information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. (See HIPAA Notice of Privacy Practices forms, provided to me, for more details of confidentiality and other issues I also understand that the dissemination of any personally identifiable images or information from the teletherapy interaction to researchers or other entities shall not occur without my written consent.
(3) I understand that there are risks and consequences from telehealth. These may include, but are not limited to, the possibility, despite reasonable efforts on the part of my psychologist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; the electronic storage of my medical information could be accessed by unauthorized persons and/or misunderstandings can more easily occur, especially when care is delivered in an asynchronous manner. In addition, I understand that telehealth-based services and care may not yield the same results nor be as complete as face-to-face service. I also understand that if my psychologist believes I would be better served by another form of service (e.g. face-to-face service), I will be transitioned to that service delivery with this group, if it is logistically possible for me, or referred to a psychologist in my area who can provide such service.
(4) I understand that I may benefit from teletherapy, but results cannot be guaranteed or assured. The benefits of telehealth may include but are not limited to: transportation and travel difficulties are avoided; time constraints are minimized; and there may be a greater opportunity to prepare in advance for sessions.
(5) I understand that I have the right to access my medical information and copies of medical records in accordance with North Carolina law. I have read and understand the information provided above, which has also been explained to me verbally. I have discussed it with my psychologist, and all of my questions have been answered to my satisfaction.
(6) I understand that insurance companies may revoke the coverage/reimbursement for telehealth services at any point and Pediatric Advanced Therapy is not responsible for these changes.
(7) I understand that it is required that the client is in the state of NC in order for sessions to be conducted due to state licensing requirements. I understand that if I am out of state, my session will be cancelled and rescheduled.