WGM Psychology and Associates
Suite 500, 609 - 14th Street N.W.
Calgary, AB T2N 2A1
1-403-444-9022
wgmpsych.com
helpnow@wgmpsych.com
Neuropsychological Services Agreement
Thank you for joining us at WGM Psychology and Associates. We are committed to providing
you with the highest standard of service, and look forward to working with you.
It is important that you understand the nature and limits of the assessment that you are initiating.
Please review this document carefully, as you will be asked to sign this document in order to
demonstrate your understanding. Please let us know if you have any questions, comments, or
concerns.
1. Referral Source
You have been referred for a medical-legal neuropsychological assessment by INSERT NAME
HERE, LLB.
2. Reason(s) for Referral: Neuropsychological Evaluation re: Motor Vehicle Accident
The goal of a neuropsychological assessment is to determine the level of your cognition and
psychological function (for example, your ability to pay attention, your ability to remember
information, the presence or absence of symptoms of depression). A neuropsychological
assessment may point to changes in brain and psychological functioning, shed light on
underlying biological changes in the brain, and suggest diagnoses. It can also help with
recommendations for treatment and rehabilitation after injury. In addition to asking you
questions about your background and current symptoms, we may also ask your permission to
talk to a family member or friend who knows you well. We will also review information from
your medical records. Testing may include asking questions about your knowledge of certain
topics, reading, drawing figures and shapes, listening to information, viewing printed material,
manipulating objects, and completing psychological questionnaires. The assessment process
will produce a written report, which will summarize your history, present the results of the
assessment and outline any conclusions, diagnoses and recommendations related to your
particular case. We will also provide a one hour feedback session with you to review your
results at the end of the assessment process.
Report Distribution: The results of your assessment are shared with your lawyer(s). This may be
verbally and/or by way of a written report. We will not release information to anyone else
without consent from your lawyers, except where required by law.
INITIAL _______
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WGM Psychology and Associates
Suite 500, 609 - 14th Street N.W.
Calgary, AB T2N 2A1
1-403-444-9022
wgmpsych.com
helpnow@wgmpsych.com
3. Qualifications
WGM Psychology and Associates is a collaborative practice of doctoral-level psychologists. This
means that all of our neuropsychologists have received the highest level of training (having
earned either a Ph.D.) and are Registered Psychologists with the College of Alberta
Psychologists.
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4. Confidentiality & Limits of Confidentiality
All communications with your treating psychologist and all records relating to the provision of
psychological services are confidential and cannot be disclosed without your written consent (or
the consent of a guardian). However, there are certain situations in which your psychologist is
legally and ethically obligated to limit the confidential nature of the psychological services
provided to you. These situations include:
Imminent danger to self or others
If your psychologist believes that you present an imminent danger to yourself or others, the law
requires that steps be taken to prevent such harm. These steps can include contacting a third party
or the authorities for this purpose.
Abuse/neglect of children or vulnerable adults
If a child or vulnerable adult is in need of protection, a report must be filed with the appropriate
agency or authority, which will also be documented in the clinical file.
Court orders
If a court orders the disclosure of records. Your psychologist may also be ordered to appear as a
fact or expert witness.
In addition, please note that:
• individuals referred for assessment and/or treatment by a third party payer can assume
that the referring party may want to receive some type of report and/or evaluation as
treatment progresses;
• if you are a minor, a guardian may have the right to impose a limit on your right to
confidentiality;
• your psychologist is required to provide necessary information if contacted by a coroner
or medical examiner.
Finally, please note that your psychologist cannot guarantee confidentiality if you contact
her/him via e-mail, or if you ask her/him for a response via e-mail.
INITIAL _______
2
WGM Psychology and Associates
Suite 500, 609 - 14th Street N.W.
Calgary, AB T2N 2A1
1-403-444-9022
wgmpsych.com
helpnow@wgmpsych.com
Collaborative care
Psychologists often consult with one another in order to ensure we are providing the standard of
excellence in mental health care you expect. By initialing this portion of the consent form, you
are providing permission for your psychologist to consult with his/her colleagues as appropriate.
Your case will be discussed without revealing your identifying information. If you would
prefer your psychologist not consult colleagues, please discuss this with him/her at the time of
your initial session.
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Contact information/Crises and emergencies
To speak with your psychologist, please call the WGM front desk at 403-444-9022. If you
psychologist is not immediately available, s/he will respond to your message as soon as possible.
If your concern is of an urgent nature, you may choose to contact an alternate source of support,
including:
•
•
•
Calgary Distress Line, 403-266-1605 (24-hour support)
Mental Health Walk-In, South Calgary Health Centre (call 403-943-9374 for hours of
operation)
Your local hospital's emergency department
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5. Clinic Operations
Appointment scheduling
WGM is open 7 days a week, from 7am to 7pm. Assessment length and frequency may vary
according to your needs; you and your psychologist will develop an appropriate plan for you
during your first meeting.
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Chart notes
A final report and test data are completed at the end of each assessment and are securely
managed. WGM maintains electronic and hard copy clinical records. We employ a HIPAcertified system which adheres to all standards required for management of records for
psychologists. You may review the contents of your file upon request. We are legally obligated to
retain your file for ten years, after which time your file will be destroyed.
INITIAL _______
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WGM Psychology and Associates
Suite 500, 609 - 14th Street N.W.
Calgary, AB T2N 2A1
1-403-444-9022
wgmpsych.com
helpnow@wgmpsych.com
Fee disclosure
Fees for information/general appointments are charged at the rate of $200/hour, and may be paid
via cash, cheque, or credit card (Master Card, Visa, and American Express). Fees for service are
required at the end of the assessment process. Requests for additional psychological reports after
an assessment is complete or for other purposes are also conducted at the rate of $200/hour.
Services conducted for legal purposes are billed at the rate of $300 per hour. Our fees are based
on the Psychologists' Association of Alberta's Recommended Fee Schedule for 2015. In medicallegal contexts, your lawyer has requested this assessment and typically covers fees for this
assessment.
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Cancellation policy
We require that you notify us at least 24 hours in advance should you need to cancel or
reschedule an appointment. There is a $200 charge for missed appointments and appointments
that are cancelled late. Please note that third-party payers (e.g., insurance companies) do not
usually cover cancellation fees. In these instances, you will be responsible for payment of these
fees.
After one missed appointment without notification, we will require payment for services are
made prior to treatment sessions and that your credit card information be placed on file.
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6. Consent to Participate in Neuropsychological Assessment
I have read and understood the policies and conditions described in the preceding sections. I have
had a chance to ask questions about them and am satisfied that my questions and concerns have
been addressed. I consent to participate in psychotherapy with the full knowledge and
understanding of these policies.
_____________________________
_____________________________
____________________
Name (please print)
Signature
Date
_____________________________
_____________________________
____________________
Witness Name (please print)
Witness Signature
Date
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WGM Psychology and Associates
Suite 500, 609 - 14th Street N.W.
Calgary, AB T2N 2A1
1-403-444-9022
wgmpsych.com
helpnow@wgmpsych.com
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