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Consent for Psychological Assessment Services
I acknowledge that I have requested a Psychological, Psychoeducational, or Neuropsychological Assessment. I understand that Dr. Tompkins is registered with the College of Psychologists of Ontario.
I understand that the assessment will involve gathering of background information through a review of medical/academic information (if applicable), clinical interviews, and completion of questionnaires. I understand that I will also be administered a number of measures to evaluate cognitive (thinking) skills, such as general intellect, language, visual perceptual/spatial abilities, processing speed, attention, working memory, learning and memory, executive functioning, academic skills, motor functioning, and behavioral/emotional functioning. I understand that a Psychometrist may be involved in the administration of these measures.
Limits to Confidentiality
I understand that the information shared with Dr. Tompkins is kept confidential and is not shared with third parties without written consent. The information will be summarized in the assessment report, which will be released to me for distribution as I see fit.
The following are situations where legal and ethical considerations prevent confidentiality from being maintained and information may be released with or without my consent:
  1. If there is a clear reason to believe you or anyone taking part in the assessment is at risk of hurting yourself/themselves or someone else, then a psychologist must take action to protect you/them or a third party even if this means breaking confidentiality.
  2. In cases of suspected child abuse of a child under the age of 16, including physical, sexual, or emotional abuse, or cases of neglect, psychologists must immediately report their concerns to Family and Children’s Services.
  3. If it is discovered that a regulated health care professional (e.g., physician, massage therapist) has sexually abused, assaulted, or harassed a patient, a psychologist must report that practitioner to their regulatory body. We are not required to identify the patient unless we have received permission to do so, or there is an order to release the patient’s name by the practitioner’s College.
  4. The contents of my file may be released if subpoenaed by a court of law.
  5. Psychologists’ records and files may be reviewed by the College of Psychologists for quality assurance purposes and complaint investigations.
  6. In cases of suspected abuse or neglect of a resident of a retirement home or long-term care facility, this information will be disclosed to the appropriate authority (i.e., Registrar of the Retirement Homes Regulatory Authority or the Director within the Ministry of Health and Long-Term Care). The harm/risk of harm may result from: improper or incompetent treatment or care; abuse by anyone; neglect by staff; unlawful conduct; misuse or misappropriation of a resident's money.
I acknowledge that I am aware of the fees for psychological assessment services, which include the interview, testing session(s), test scoring and interpretation, report writing, and feedback session. Additional agreed upon services (e.g., preparing additional reports or letters, phone consultations) will be billed separately at the rate of $200 per hour. I understand that partial payment is due at the initial appointment, with the balance payable at the feedback session. It is my responsibility to determine what insurance coverage I have and to submit the receipts to the insurance company for reimbursement.
Occasionally, third party insurance providers contact Dr. Tompkins to verify that claims submitted match the services provided. In these instances, the insurance company will ask for the name, date of services provided, and associated fees, but will not require any information about what was discussed in session or the reasons for the session.
I give permission for Dr. Tompkins to communicate with my insurance company for the purposes of validating my claims. I understand that the only information provided to the insurance company will be client’s name(s), date(s) of service, and fees.
Email Communication
If you communicate with Dr. Tompkins by email, please be aware that email is not a completely confidential form of communication, and as such, you are encouraged to limit the amount of personal health information that you email.  If you choose to email Dr. Tompkins personal information, you are accepting the risk that your information may not be confidential. We do use email to send appointment reminders, which contain little personal health information.
Cancellation Policy
I understand that 48-hours notice is required to cancel or reschedule an assessment. If I do not give sufficient notice or I fail to show up to an assessment, I will be charged a missed appointment fee of $200.00. The fees for missed appointments are usually not covered by third party insurance providers.
I acknowledge that I have been given an opportunity to ask questions related to this consent. I understand and consent to all of the above conditions and I hereby consent to participate in this assessment process.
Thank you for submitting!
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