Institute for the Advancement of Psychotherapy
      Trusted, Compassionate, and Effective Psychological Treatment
      Center for Anxiety, Center for ADD/ADHD, Center for Couples, Center for Adolescents, and Oppositional and Conduct Clinic

(415) 881-7324                         Marin              San Francisco            Berkeley


      Welcome to our practice. This document contains important information about our professional
      services and business policies. Please read it carefully and jot down any questions you might have
      so that we can discuss them at our next meeting. When you sign this document, it will represent
      an agreement between you and your therapist.

      Many people come to us for psychological assessment services to gain a greater understanding of
      their or their child’s strengths and weaknesses so that they can develop a strategy for success.
      The reason for assessment may include improving school performance, understanding
      psychological problems that are getting in the way of functioning, or obtaining documentation of

      The first step in the process is to talk with you and learn what the question is that we are trying to
      answer through psychological testing. We will also talk with the referring party, whether that be
      the school or a therapist or some other source to determine what is needed. If a psychological
      assessment is not needed, then we will charge time spent on the consultation at __________. If it
      is decided that testing is needed, the fee for the consultation will be included in the rate of the

      It is important to note that if the referral is for a child with learning problems or other conditions,
      which significantly impact learning, he or she may be eligible for a psychoeducational assessment
      by the public school system free of charge. Assessment at the school site is for purposes of
      determining if your child has a disabling condition that requires specialized instruction or related
      services and accommodations. You may be able to determine this by speaking with your child’s
      school counselor, school psychologist, administrator, or other Special Education staff member at
      the school. When consulting with the referring party and the school, we will be checking to see if
      your child is eligible for an assessment by the school system. Generally the child needs to be
achieving below the average student level or in some cases below his or her ability level in order
to be eligible for assessment by the school. This means that if the child is doing generally well in
school, they may not be eligible for assessment regardless of other factors, such as attention
problems.    Also, the assessments by the school do not often include psychodiagnostic and
neuropsychological assessment measures, so if these assessments are indicated, further testing
outside of the school may be appropriate or necessary.

Also, it is important to note that there are benefits and risks to having a psychological assessment.
The benefits include a clearer picture of the client’s strengths and weaknesses, which help in
designing a plan to compensate for weaknesses by using strengths. Another benefit is that having
a clearer clinical picture can inform treatment. Also, finally learning what the problem is that the
person is having often helps alleviate a sense of shame and failure and may decrease significant
others’ frustration. Lastly, assessment is often needed to obtain resources that are required to be
available by law to individuals with disabilities.

Some of the risks involved with testing are that it can be unpleasant to sit through numerous
difficult tests for several hours. The testing itself can cause some anxiety and frustration.
Another risk of the assessment is that it may bring to light issues that have never been discussed,
thus causing some unpleasantness and disagreement or conflict in relationships. Also, sometimes
getting a clear diagnostic picture can leave the person experiencing unpleasant feelings due to
stigma of having a particular problem or area of weakness. Lastly, a risk for some people is that
they may not be eligible for accommodations that they are hoping they will be eligible for.

Your therapist will conduct a clinical interview with the person being assessed and their family (if
appropriate) for one hour to gain a great understanding of the problem and have releases signed
so that your therapist can contact the referring party if the assessment has not been self referred.
During the interview your therapist will be taking a family history, medical history, psychiatric
history, educational history, developmental history, and trying to gain as much information about
the person that can help understand the current difficulties. If a full assessment is needed, we will
discuss amount of time the testing will take. For example, for a full psycho-educational
evaluation, your therapist usually meets with the student for two sessions for four to five hours
each or three sessions of three to four hours each. These sessions are usually held on a weekdays,
starting mid morning, which gives optimal time for performance and parallels an average school
day. Clients are encouraged to bring snacks and/or lunch with them to the appointment.

Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 48
hours advance notice of cancellation. You will be charged a fee for missing the session if
canceled in less than 48 hours at a rate of _____________.

_________________ is a _______________ in the state of California, License #_____________.
Therapist’s Name                 Title

Your therapist’s hourly fee is ___________ and for a full psychoeducational assessment, your
therapist charges __________. The full assessment includes the clinical interview, interviews of
the referring parties, reviewing records, the testing sessions (cognitive, neurospych, and
educational assessments, but not including personality assessment), scoring of the tests, the
presentation of the results to the clients, and a consultation and presentation of results to the
school (if requested). To add a personality assessment (this goes deeper into psychological issues
such as anxiety, depression, bipolar disorder, etc.) to the battery, then it will be an additional
charge of $600

Payment for the consultation to determine if the assessment is needed is required at the time of
the meeting. If it is decided that a full assessment is indicated, then the first half of the payment
will be due at the consultation meeting and the second half will be due at the first assessment
meeting. Your therapist will not begin working on the report until payment has been made, but of
course if you would like to discontinue the testing at any time, then you will receive a refund of
the amount left over after paying for the time your therapist has already worked on your report
and time spent doing the assessment.

If there is a need to cancel or change the appointment, this must be done 48 hours before the
appointment. If the client cancels in less than 48 hours, then they will be charged the rate of
______ for each hour of the session that was scheduled (for example: if four hours have been
scheduled, then the charge will be ______).
If your account has not been paid for more than 60 days and arrangements for payment have not
been agreed upon, we have the option of using legal means to secure the payment. This may
involve hiring a collection agency or going through small claims court. If such legal action is
necessary, its costs will be included in the claim. In most collection situations, the only
information we release regarding a patient’s treatment is his/her name, the nature of services
provided, and the amount due.

If you have a PPO plan, we will provide you with a receipt if requested, and you can submit this
to your PPO, which may reimburse part of the fee, although some plans will not reimburse.

You should call your insurance company to find out what the coverage for the assessment may
be, ask what your deductable is, what percentage they pay, and what the customary rate is. Your
therapist will provide you with whatever information he/she can based on his/her experience and
will be happy to help you in understanding the information you receive from your insurance
company. If it is necessary to clear confusion, your therapist will be willing to call the company
on your behalf and will prorate the hourly fee depending on how long it takes to clear the
confusion (this fee will not be covered by the insurance company).           Also, understand that
sometimes what insurance companies initially quotes as coverage may not end up being what
they pay. They sometimes can take a few months before making payments, so please be prepared
when budgeting your finances.

Your therapist is often not immediately available by telephone because he/she does not answer
the telephone while with clients. You can call or text them at their phone at ____________ or
email them at ___________________ and he/she will try to respond as soon as possible. If you
are difficult to reach, please inform your therapist of some times when you will be available. If
you are unable to reach your therapist and feel that you can’t wait for a returned call, contact your
family physician or the nearest emergency room and ask for the psychologist on call. If your
therapist will be unavailable for an extended time, he/she will provide you with the name of a
colleague to contact, if necessary.
The laws and standards of our profession require that your therapist keep treatment records. Your
therapist will provide you a copy of the psychological assessment once it has been completed.
Your therapist can also provide an edited version of the report for schools or testing agencies
(e.g., GRE, MCAT) if you’d like personal information removed that is not applicable to the
school or agency. Your therapist will discuss what is applicable as some personal history may be
integral in the diagnosis and recommendations. Your therapist will work with you on presenting
the information in a mutually acceptable manner.

If you are under eighteen years of age, please be aware that the law provides your parents the
right to examine your treatment records. Your therapist will try to provide them only with general
information about our work together, unless your therapist feels there is a high risk that you will
seriously harm yourself or someone else. In this case, your therapist will talk with you and
encourage you to discuss the issue with them; otherwise your therapist may have to notify them
of his/her concern. In the paragraph below, we explain to your parents that we may not tell them
information, even if you are engaging in high risk behavior such as drug use, risky sexual
behavior, or other risky behavior, but your therapist will work with you and your family to
encourage you to discuss these issues at some point. Before giving your parents any information,
your therapist will discuss the matter with you, if possible, and do his/her best to handle any
objections you may have with what her/she is prepared to discuss. In general, what we talk about
is private and your therapist will consult you before any information is brought into family
therapy, but please also let me know if there is something that you don’t want your therapist to
tell your parents and your therapist will do his/her best to hold that confidential.

During the assessment, your therapist will be open with information that is exchanged between
family members, rather than the traditional confidentiality, but your therapist will talk with you
and your children first about discussing anything you have told your therapist privately. Not
everything is appropriate for everyone in the family to know and in some cases; information must
be kept private to maintain a trusting relationship between the therapist and minor. Your therapist
will tell you if your child is in danger, but your child may not discuss high-risk behavior unless
your therapist makes it safe. This means that your therapist may not report substance use, risky
sexual behavior, or other risky behaviors right away. Your therapist will work with your child in
helping them to talk to you about these issues and will work with you to improve your
communication with your child around these issues.

In general, the privacy of all communications between a patient and a psychologist is protected by
law, and your therapist can only release information about our work to others with your written
permission. But there are a few exceptions.

In most legal proceedings, you have the right to prevent your therapist from providing any
information about your treatment. In some proceedings involving child custody and those in
which your emotional condition is an important issue, a judge may order your therapist’s
testimony if he/she determines that the issues demand it.

There are some situations in which your therapist is legally obligated to take action to protect
others from harm, even if your therapist has to reveal some information about a patient’s
treatment. For example, if your therapist believes that a child, elderly person, or disabled person
is being abused, he/she must file a report with the appropriate state agency.

If your therapist believes that a patient is threatening serious bodily harm to another, your
therapist is required to take protective actions. These actions may include notifying the potential
victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to
harm himself/herself, the therapist may be obligated to seek hospitalization for him/her or to
contact family members or others who can help provide protection.

Lastly, if you are threatening serious harm to yourself your therapist may have to break
confidentiality. Your therapist will discuss this with you and we may look at the option of
hospitalization if your therapist is concerned that you are in danger of committing suicide.

These situations have rarely occurred in my practice. If a similar situation occurs, your therapsit
will make every effort to fully discuss it with you before taking any action.

Your therapist may occasionally find it helpful to consult other professionals about a case. During
a consultation, your therapist will make every effort to avoid revealing the identity of the patient.
The consultant is also legally bound to keep the information confidential. If you don’t object,
your therapist will not tell you about these consultations unless he/she feels that it is important to
your work together.

Lastly, we will review the assessment report together and decide who you would like to have see
the report. Often, it is very helpful for therapists to have all the information in a report, while
schools may not need all the family history details. Once everyone has reviewed the report, we
can decide who will see it and if any changes need to be made before it goes to another party.
This does not mean that your therapist can withhold information important to the understanding
of the problem, but we can omit information that may not seem relevant.

This document attempts to outline all the policy and procedures involved in having
________________ conduct a psychological assessment. It is important that we discuss any
questions or concerns that you may have at our next meeting. I will be happy to discuss
these issues with you if you need specific advice, but formal legal advice may be needed
because the laws governing confidentiality are quite complex, and I am not an attorney.

Your signature below indicates that you have read the information in this document and
agree to abide by its terms during our professional relationship

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Client(s)                                                          Date

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