Client Name I,(client/parent/legal representative) agree to allow Dr. Beatriz Amador to perform the following services Psychological/Neuropsychological testing, assessment, or evaluationPsychotherapyOther (describe) I understand that these services may include direct, face-to-face contact, interviewing, or testing. They may also include interviews with other sources (e.g., family members), and review of collateral documents (e.g., mental health treatment records, medical records). Services may also include the psychologist’s time required for the reading of records, consultations with other psychologists and professionals, scoring, interpreting the results, and any other activities to support these services. I understand that all information obtained while I receive treatment/services by Dr. Beatriz Amador is confidential and will not be disclosed to anyone without my express written permission or a court order as required by applicable Federal and State Laws. I also understand that Dr. Beatriz Amador has a legal obligation to break confidentiality in cases of child or elderly abuse or neglect and in circumstances where clients or others deemed to be at risk of suicidal or homicidal behavior. I understand that I may terminate the evaluation at any time, and if needed, allowed to contact my attorney. PAYMENT AGREEMENT I agree to sign any insurance authorization form in order to facilitate the process of collecting the reasonable fees for the services provided. I also agree to pay the amount of un-reimbursed established fees by the insurance company. I understand that the fee for this (these) service(s) will be payable at the time these services take place. Though my health insurance may repay me for some of these fees, I understand that I am fully responsible for payment of these services. I have read and understand this form in its entirety and I understand the purpose of the evaluation/treatment and my options regarding participation. I hereby consent to the mental health services offered by Dr. Beatriz Amador. Signature of Client (or parent/guardian) Date I agree that my submitted data is being collected and stored. Δ
