Consent and agreement for psychological testing by H2yE7H


									                                           Office of Louisa A. Parks, Psy.D.
                Consent and Agreement for Neuropsychological Testing and Evaluation

I, ______________________________________, agree to allow Louisa A. Parks, Psy.D. to perform the following
❑ Psychological testing, assessment, or evaluation, scoring, interpretation, and report generation
❑ Consultation with school personnel (if applicable)
❑ Consultation with lawyers (if applicable)
❑ Deposition (that is, written or oral testimony given to a court, but not made in open court)
❑ Testimony in court
❑ Other (describe): _______________________________________________________________________________

This agreement concerns ❑ myself or ❑ _________________________________________________________ .
I understand that these services will include direct, face-to-face contact, interview, and testing that will take
approximately six to seven hours. Depending on my attention and stamina levels, this portion of the service may be split
into two sessions of approximately 3 hours each. Services may also include the psychologist’s time required for the
review of records, consultations with psychologists and other professionals, scoring of tests, interpreting results, and any
other activities required to support these services. The service also includes one follow-up session to present and
discuss the results of testing and accompanying recommendations.
I understand that the fee for this these services will be $165.00 per hour, and that this is payable in two parts: a deposit
of $ $1,250.00 payable before the start of services, and a second payment of the balance due on the completion and
delivery of any report. Fees for testimony in court, depositions, and consultation with attorneys (and any other services
related to a lawsuit or court case, including travel time) are $350.00 per hour. I understand that I am fully responsible for
payment for these services should the case go against me and/or my insurance company does not pay for Dr. Parks'
I understand that this evaluation is to be done for the purpose(s) of: _________________________________________

I also understand the psychologist agrees to the following:
1. The procedures for selecting, administering, and scoring the tests, interpreting the results, and maintaining my privacy
will be carried out in accord with the rules and guidelines of the American Psychological Association and within
applicable state and federal laws.
2. Tests will be chosen that are suitable for the purposes described above. Scores will be interpreted according to
scientific findings and guidelines.
3. Tests and test results will be kept in a secure place to maintain their confidentiality.
4. The report of the findings of this assessment will be sent to ____________________________________________ .

I agree to participate fully by supplying truthful, complete answers and by making an honest effort in order to ensure that
findings are accurate.

_______________________________________________________                      _____________________________________
Signature of client (or parent/guardian)                                     Date

I, Louisa A. Parks, Psy.D., have discussed the issues above with the client (and/or his or her parent or guardian). My
observations of this person’s behavior and responses give me no reason, in my professional judgment, to believe that
this person is not fully competent to give informed and willing consent.

_______________________________________________________                      ____________________________________
Signature of psychologist                                                    Date

❑ Copy accepted by client ❑ Copy kept by psychologist
        This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.

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