Informed Consent for Psychological Assessment Welcome to the Office of Ramesh B. Eluri, MD, PC (RBE). This form will provide information about our psychological assessment services and about your rights and responsibilities as a client. Please be sure to discuss any questions with your clinician or his/her Supervisor. Your signature at the bottom indicates that you understand the information and freely consent to participate in this assessment. We utilize both Licensed Psychologists and Psychology Residents to complete the assessment process. Psychology Residents are doctoral level clinicians under the supervision of Licensed Psychologists with expertise in psychological, educational, and cognitive assessment. In order to ensure the best possible service, your clinician will be discussing your testing results with her/his supervisor(s). TESTING Through the use of a variety of standard psychological tests, we will attempt to answer the questions that have brought you for this assessment. These questions generally concern learning disabilities, academic functioning, personality functioning, or coping styles. Throughout the assessment process you have the right to inquire about the nature or purpose of all procedures. You also have the right to know the test results, interpretations, and recommendations. The assessment process consists of three appointments: intake session, testing session of one or more educational and/or psychological tests, and a feedback session to review the results. Although it is sometimes possible to complete the testing in one sitting, it is common for clients to be asked to return for another session to finish the assessment battery. Once testing is completed, the data will be analyzed and a comprehensive report will be written. You will then have the opp01tunity to meet with a Licensed Psychologist to discuss the results and receive a copy of the report. Typically this feedback session will take place about three weeks from the time that all psychological testing is completed. FEE AND PAYMENT POLICY The fee for an evaluation is based on the type of tests included in the assessment battery and the number of billable hours. Any adjustment to the standard fee will be noted in the space below. If you are utilizing your insurance for this assessment, you will be responsible for your co-pay for each appointment as dictated by your insurance. Should your insurance company require this will be completed to scheduling your testing appointment. If your insurance pre-authorizes the assessment, but chooses to later reject the authorization after the assessment is complete, you are responsible for full payment of the assessment.
Informed Consent for Psychological Assessment Welcome to the Office of Ramesh B. Eluri, MD, PC (RBE). This form will provide information about our psychological assessment services and about your rights and responsibilities as a client. Please be sure to discuss any questions with your clinician or his/her Supervisor. Your signature at the bottom indicates that you understand the information and freely consent to participate in this assessment. We utilize both Licensed Psychologists and Psychology Residents to complete the assessment process. Psychology Residents are doctoral level clinicians under the supervision of Licensed Psychologists with expertise in psychological, educational, and cognitive assessment. In order to ensure the best possible service, your clinician will be discussing your testing results with her/his supervisor(s). TESTING Through the use of a variety of standard psychological tests, we will attempt to answer the questions that have brought you for this assessment. These questions generally concern learning disabilities, academic functioning, personality functioning, or coping styles. Throughout the assessment process you have the right to inquire about the nature or purpose of all procedures. You also have the right to know the test results, interpretations, and recommendations. The assessment process consists of three appointments: intake session, testing session of one or more educational and/or psychological tests, and a feedback session to review the results. Although it is sometimes possible to complete the testing in one sitting, it is common for clients to be asked to return for another session to finish the assessment battery. Once testing is completed, the data will be analyzed and a comprehensive report will be written. You will then have the opp01tunity to meet with a Licensed Psychologist to discuss the results and receive a copy of the report. Typically this feedback session will take place about three weeks from the time that all psychological testing is completed. FEE AND PAYMENT POLICY The fee for an evaluation is based on the type of tests included in the assessment battery and the number of billable hours. Any adjustment to the standard fee will be noted in the space below. If you are utilizing your insurance for this assessment, you will be responsible for your co-pay for each appointment as dictated by your insurance. Should your insurance company require this will be completed to scheduling your testing appointment. If your insurance pre-authorizes the assessment, but chooses to later reject the authorization after the assessment is complete, you are responsible for full payment of the assessment.
Informed_Consent_for_Psychological_Assessment.docx