I acknowledge that I have requested a Psychological, Psychoeducational, or Neuropsychological Assessment for myself or my child from Dr. Season Tompkins.

 

I understand that Dr. Tompkins is registered with the College of Psychologists of Ontario to work with adults and seniors and is currently completing additional supervised training to work with children and adolescents. I understand that Dr. Tompkins will be supervised by Dr. Katherine Spere and/or Dr. Kathy Smolewska throughout the assessment process for children and adolescents. Dr. Spere is registered with the College of Psychologist of Ontario and can be reached at 519.513.2441 or by email at kspere@kitchenerpsych.com. Dr. Smolewska is registered with the College of Psychologist of Ontario and can be reached at 519.505.4182 or by email at info@drkathysmolewska.ca.

 

I understand that the initial interview will gather information about me/my child related to developmental and academic history, as well as current concerns and goals. I am aware that psychometric testing will be done over 1-3 sessions, typically, which will include standardized assessment measures for cognitive ability, memory, and academic achievement. A Psychometrist, someone trained in the administration of the standardized tests, may be involved in the assessment process. The testing sessions can be mentally draining for children, but usually children enjoy the sessions. They do not know how they are performing relative to other children and usually do not find the sessions overly stressful. Parents, teachers, and sometimes children will be asked to complete standardized questionnaires. Following the testing, Dr. Tompkins will score and interpret the data and will write a report integrating all the information. Sometimes the assessment will result in a diagnosis (e.g., learning disability, Attention Deficit Hyperactivity Disorder), sometimes it does not. Either way, the report will outline my/my child’s strengths/weaknesses and will provide recommendations for home, work, and/or school. 

 

The potential risks and benefits of psychological assessment have been explained to me. I understand that I can withdraw my consent at any time.

 

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 assessment results will be shared with me (and age dependent, with my child) during a feedback session. I will receive a copy of the report following the feedback session. Written permission is required in order for Dr. Tompkins to share the report or to discuss results with any third parties (e.g., teacher, family physician).

 

I understand that Dr. Tompkins will be discussing my case with Dr. Spere and/or Dr. Smolewska for supervision purposes, but that they will also keep my information confidential.

 

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/your child are/is at risk of hurting yourself/themselves or someone else, then a psychologist must take action to protect you/your child 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 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 your file may be released if subpoenaed by a court of law, or as required by the Missing Persons Act.

5. Our records and files may be reviewed by the College of Psychologists for quality assurance purposes and complaint investigations.

6. In cases of suspected abuse of 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.

 

Fees

 

I acknowledge that I am aware of the fees for this psychological/neuropsychological assessment, which include the initial interview, testing, test scoring and interpretation, report writing, and the feedback session. Additional agreed upon services provided following the assessment (e.g., preparing letters, school consultations), will be billed at the hourly rate of $200/hour. I understand that payment is due as outlined in my appointment confirmation letter and 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 and date of services provided, 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 names and dates of service.

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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 consultation or treatment process.

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