Informed Consent for Psychological Testing
This form is intended to give you an overview of your rights and responsibilities as a client and
purpose of assessment. If you have any questions about anything mentioned in this form, please
feel free to reach us at:
Ellie Wilcox (Counselor-In-Training)
WIL08736@pennwest.edu
Client Rights
● You have a right to discontinue evaluation at any point.
● You have a right to ask about the nature, intent and methods of the assessment.
● You have a right to access your records.
● You have a right to seek another opinion following assessment results.
● You have a right to file a complaint if you feel your rights have been violated, without
retaliation
○ You can complain if you feel we have violated your rights by contacting us using
the information on page 1.
○ You can file a complaint with the U.S. Department of Health and Human Services
Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W.,
Washington, D.C. 20201, calling 1-877-696-6775, or visiting
https://www.hhs.gov/hipaa/filing-a-complaint/index.html.
Risks and Benefits of Assessment
The purpose of this assessment is to conduct accurate testing that allows your care providers to
develop a tailored treatment plan suited to your specific needs. The results can provide a better
understanding of yourself, and a diagnosis may assist in acquiring necessary educational or
occupational accommodations.
Please be aware that the nature of the assessment questions may invoke emotional distress.
Additionally, there are financial considerations if insurance does not provide full coverage or is
not utilized. Other potential risks include the implications of diagnostic labeling and the
possibility of misdiagnosis.
Confidentiality and Limits to Confidentiality
Any information shared in assessment is considered privileged and will be kept confidential.
Results will only be shared with authorized personnel who are qualified to interpret the results,
and who have received your written consent to review your records. However, there are a few
circumstances where confidentiality must be broken:
1. If you threaten to hurt or kill yourself or someone else
2. If there is suspected abuse of a child, an elder, or other vulnerable individuals
3. If your records are subpoenaed. If this were to happen, I would only share what is
required by the court.
4. If you are a minor, I am required to share your records with your parents or
guardian if requested.
5. The assessor may share details of your case with a qualified supervisor to ensure
they are providing the best service. Specifics of your identity will not be shared.
There is an inherent risk by using virtual communication. Patient information will be stored in an
Electronic Health Care system as required for billing and treatment purposes. Please use caution
when sharing sensitive information by email or text.
Scope of Professional Relationship
The relationship between assessor and assessee is purely professional, and intended to ensure
that an accurate psychological assessment is conducted. These are not therapeutic treatments.
Fees and Payment Policies
Payment is expected by the time of assessment. There may be costs not covered by your
insurance policy. You will be responsible for any costs not covered by insurance. Payment plans
are accepted but do not exceed durations of 6 months.
Cancellations must be confirmed as soon as possible, but no less than 24 hours before the
session. Failure to notify the office of a necessary cancellation and any missed sessions will incur
a $25 non-refundable fee.
Emergency Procedures
If an emergency arises during your assessment and it is evident that you are in immediate danger,
it may be necessary for us to contact your emergency contact or emergency services. We will
make every effort to ensure both your safety and your confidentiality throughout this process.
If an emergency occurs outside of the assessment, please contact 911 or the RESOLVE Crisis
Services at (888) 796-8226 for immediate assistance.
Records
Your records will be saved for 7 years from the last date of service as required by law. As
previously stated, you have a right to review your records. You can request an electronic or paper
copy of your medical records. Please message wil08736@pennwest.edu to request this.
Your signature below ensures that you have read and agree to the policies and procedures
outlined in this informed consent form.
Client’s Name: ________________________________________
Client’s Signature: _____________________________________ Date: ___________________
Parent/Guardian Signature: ______________________________ Date: ___________________
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