This form is for individuals under the age of 18 and is intended to help us better understand a young person's background, needs, and support system.

If you are 18 years or older, please request and complete the Adult Intake Form instead.

This form may be completed by the child or teen themselves, or by a parent or legal guardian. Unless a question specifically asks about the parent/guardian, all questions should be answered based on the child’s/teen's information and experiences.

Please answer as fully and honestly as you can. If you are unsure about something, it's okay to say "I don't know".

Allow 30 minutes to 1 hour to complete the form.

Here’s a short welcome message from Dr. Brinson before you get started:

In your previous response, if you did not list yourself as the parent or the patient, please provide who is the legal guardian.

Who is the child’s legal guardian or custodial authority?

Parent

Legal Guardian

State Custody / Foster Care

Unknown

Legal Guardian's First Name

Legal Guardian's Last Name

Legal Guardian's Contact Number

Legal Guardian's Email

Anything else we should know?

Moving forward, Unless a question specifically asks about the parent/guardian, all questions should be answered based on the child’s/teen's information and experiences.

First Name *

Last Name *

Phone *

Date of birth *

Age *

Gender: *

Email *

Address *

Street Address

City

State

Country

Postal code

Primary Language *

Other/Secondary Language *

Nation, Tribe, or Ethnic Background of Child *

Place of Origin *

Length of Time in Florida *

Emergency Contact Information

First name - Emergency *

Last name - Emergency *

Phone Number - Emergency *

Email - Emergency *

Who is your current legal guardian or primary caregiver? *

What is the relationship status of your biological parents? *

What is the current custody arrangement between your biological parents? *

What is your visitation arrangement with the non-custodial parent? *

If there is anything you’d like to share about your custody arrangement, please describe it here. *

Did any of the following occur during labor, delivery, or shortly after birth? (Select all that apply) *

Developmental Milestones
Please indicate the approximate age (in months or years) when each milestone was achieved. If you're unsure, you may leave it blank or write “Not sure.”

Crawled *

Put several words together *

Sat alone *

Spoke first word *

Spoke in complete sentences *

Stayed dry at night *

Toilet trained (daytime) *

Walked alone *

How would you describe the child’s early temperament? Select all that apply: *

Provide details regarding early temperament. *

These questions on the next few pages ask whether your child has ever experienced difficulties — either in the past or currently.
If you are a teen completing this form for yourself, please answer based on your memory of childhood experiences. If you're unsure, try asking a parent, guardian, or someone close to you who may know.

Does the child have difficulty understanding language? *

Does the child have difficulty using language to communicate? *

Does the child have difficulty understanding social communication (e.g., conversation rules)? *

Does the child have difficulty reading or understanding body language and nonverbal communication? *

Does the child have difficulty chewing any solid food? *

Does the child have difficulty drinking from a cup? *

Does the child have difficulty drinking through a straw? *

Does the child experience excessive drooling? *

Does the child show sensitivity to different textures of food or drink? *

Does the child have difficulty swallowing? *

Does the child have difficulty walking? *

Does the child have difficulty running? *

Does the child have difficulty jumping? *

Does the child have difficulty climbing stairs? *

Does the child have difficulty walking on uneven surfaces? *

Does the child have difficulty maintaining balance? *

Does the child have difficulty using silverware or writing utensils? *

Does the child have difficulty tying shoes, or using zippers, buttons, etc.? *

Does the child have difficulty manipulating small objects with their hands? *

Does the child show unusual responses or sensitivities to taste? *

Does the child show unusual responses or sensitivities to smell? *

Does the child show unusual responses or sensitivities to movement? *

Does the child show unusual responses or sensitivities to touch or texture? *

Does the child show unusual responses or sensitivities to visual input? *

Does the child show unusual levels of activity or general weakness? *

Does the child show other unusual responses or behaviors? (please describe) *

Does the child show unusual responses or sensitivities to auditory input or filtering sounds? *

Please explain your response above or provide any examples you feel are important: *

Level of difficulty in various areas.

Feeding themselves? *

Managing personal hygiene? *

Toileting? *

Bathing themselves? *

Dressing themselves? *

Performing assigned chores? *

Please elaborate of your above responses by going into detail. *

Unusual or Atypical Behaviors: Does your child display any of the following behaviors (check all that apply)? *

Please explain any checked atypical behaviors *

Suicidal Risk

As a reminder these questions relate to the child/teen whose having the evaluation.

How many times have you attempted suicide? *

Do you currently have a suicide plan? *

If you have a suicide plan, please describe it, including what you plan to do, whether you have access to the means to carry it out, if you’ve set a time or place, and whether you’ve shared this plan with anyone.

Have you ever had thoughts of suicide? *

What substances do you currently use? *

For each substance you selected, please describe the type, amount, and frequency of use. Type: Long Text (Example: Alcohol – beer, 3-4 times/week; Cannabis – daily; Prescription painkillers – occasional, 5 mg once a week.) *

Past substance use. If "None" indicate "None" *

Does the child show unusual or heightened responses to taste? (e.g., extreme picky eating or strong reactions to certain flavors) *

Does the child show unusual or heightened responses to movement? (e.g., frequent rocking, spinning, constant motion seeking) *

Does the child show unusual or heightened responses to smell? (e.g., avoids strong odors or seeks out certain smells) *

Does the child show unusual or heightened responses to touch or texture? (e.g., avoids certain clothing, foods, surfaces) *

Does the child show unusual or heightened responses to visual input? (e.g., sensitivity to light, fascination with patterns or motion) *

Does the child show unusual or heightened responses to sound (auditory filtering)? (e.g., sensitivity to noise, difficulty tuning out background sounds) *

Does the child show unusual activity levels or weakness? (e.g., high or low energy, tires easily, low muscle tone) *

Does the child show other unusual sensory responses or behaviors? (please describe) *

Describe any conditions at home that may be influencing the child’s development or behavior? *

List/describe any concerns about the child’s development or behavior? *

Describe any conditions at school that may be influencing the child’s development or behavior? *

Please describe the main concern or reason you are seeking support at this time. *

What do you hope to accomplish through counseling or evaluation? *

What concerns or challenges are you currently experiencing? *

Does the child have difficulty or delay in any of the following communication areas? Select all that apply: *

Has your child been involved in any of the following (please select all that apply)? *

Please elaborate on your experience in any of the above programs, if applicable.

What is your father’s current or most recent occupation *

What is your mother's current or most recent occupation *

Name all people currently living in your home. *

How many people, including yourself, live in your home (count the child)? *

Would you like to provide details about any additional people living in your home? *

Behavioral & Impulse Control - Which of the following behaviors, emotions, or challenges are currently a concern? *

Emotional & Mood Symptoms- Which of the following behaviors, emotions, or challenges are currently a concern? *

Attention & Focus Challenges - Which of the following behaviors, emotions, or challenges are currently a concern? *

Physical, Sensory, and Other Concern - Which of the following behaviors, emotions, or challenges are currently a concern? *

Neurological & Cognitive Conditions - Have you ever been diagnosed with any of the following neurological or cognitive conditions? (Select all that apply) *

General Medical Conditions - Do you currently have or have you ever been diagnosed with any of the following medical conditions? (Select all that apply) *

Do you experience any of the following physical limitations or disabilities?(Select all that apply) *

Immune, Infectious, or Chronic Illnesses - Have you ever been diagnosed with any chronic illnesses or immune-related conditions? (Select all that apply) *

Have you ever experienced any of the following? *

Please list any other medical conditions or diagnoses you’ve received that were not mentioned above, or enter None. *

Describe anything you take regularly, such as prescriptions, over-the-counter medications, vitamins, or supplements. Example: Zoloft – for anxiety – 50 mg – once per day – prescribed by Dr. King. *

If you’ve ever used alcohol or drugs, when did you first try them? *

Which of the following best describes your current or past use of alcohol, tobacco, or drugs? *

Tell us about any current or past use of alcohol, tobacco, or drugs. *

Has your child ever experienced any form of abuse or trauma? (Select all that apply) *

Please elaborate on your response(s) regarding abuse or trauma *

What is the highest grade or level of education you have completed? *

What school are you currently attending? *

What grade was repeated? (Select all that apply) *

If a grade was repeated, please provide the school name and reason for repeating. *

Please select the areas where strengths are most noticeable in a school setting. These may include academic, social, behavioral, or creative abilities. (Select all that apply): *

Please select any areas where difficulties or challenges are observed in a school setting. This will help us better understand support needs and patterns. (Select all that apply): *

Have there been any major changes in your attitude toward school? *

If you selected that there has been a change in attitude, please describe what has changed. Include any noticeable shifts in motivation, behavior, emotional response, or engagement with schoolwork or peers. *

Have you received any of the following services? *

Please explain any services checked above. Briefly describe the services selected, including when they were received, the purpose of the support, and any outcomes you’ve noticed. For example, you might note the frequency of sessions, the provider or program name, or how your child responded to the service. *

List any family members with learning difficulties (reading, writing, math, organization). *

What is your work schedule like? *

Length of employment (if applicable) *

What is your current employment status? *

Has your child ever had any legal problems or been involved with the justice system? *

Provide a brief summary of the incident, including the time frame and the resolution or consequences. *

Has your child or your family ever been involved with the Department of Children’s Services (DCS) or Department for Children and Families (DCF)? *

Please explain the nature of your involvement with the Department of Children’s Services or Department for Children and Families. *

Is there someone you can turn to for support when you need help or feel overwhelmed? *

How does your child get along with siblings or other children in the home? *

How do you get along with peers (people their age)? *

How do you get along with adults at home? *

How would you describe your friendships? *

What activities do you enjoy the most? (Select all that apply) *

What are your behavioral and social weaknesses *

What are your behavioral and social strengths? *

Would you like to add anything else? *

Consent, Permission, & Policy Acknowledgment

In order for your child to be evaluated by PsychEd Solutions, P.A., the following consent and policy forms must be completed and signed by the child’s legal guardian.

If you have any questions about these documents or need clarification before signing, please don’t hesitate to ask. We’re here to help ensure you feel fully informed and supported throughout the process.

Informed Consent for Psychotherapy

General Information
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

Confidentiality

The session content and all relevant materials to the clientʼs treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expertʼs report to an attorney

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

By signing below, I acknowledge that I am the legal guardian of the child being referred to PsychEd Solutions, P.A. I have reviewed and understand the policies provided. I give permission for my child to participate in a psychological or psychoeducational evaluation.

If you have any questions before signing, please feel free to contact us.

Parent or Legal Guardian's Consent

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NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. I. MY PLEDGE REGARDING HEALTH INFORMATION:

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.

• Give you this notice of my legal duties and privacy practices with respect to health information.

• Follow the terms of the notice that is currently in effect.

• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/clientʼs personal health information without the patientʼs written authorization, to carry out the health care providerʼs own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is: a. For my use in treating you. b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. c. For my use in defending myself in legal proceedings instituted by you. d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. e. Required by law and the use or disclosure is limited to the requirements of such law. f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes. g. Required by a coroner who is performing duties authorized by law. h. Required to help avert a serious threat to the health and safety of others.
Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyoneʼs health or safety.
For health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
For law enforcement purposes, including reporting crimes occurring on my premises
To coroners or medical examiners, when such individuals are performing duties authorized by law
For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.
Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
The Right to Get a List of the Disclosures I Have have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on September 20, 2013

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.

Signature Notice of Privacy Practices

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PRACTICE POLICIES AND PROCEDURES

Welcome & Thank you for trusting and choosing Psyched Solutions, P.A. Founded by Dr. Brinson, Psyched Solutions, P.A. offers effective outpatient, individualized solutions. We specialize in psychological and psychoeducational evaluations for children, teens and adults. We also treat several mental health disorders and provide neutral ground for individuals, couples and families. Our focus is on helping individuals heal, energize, and become aware of their inner strengths. We achieve this by providing a neutral, safe space; listening to your concerns and customizing an individualized treatment plan. Our goal is to help you grow from your struggles, heal from your pain and move forward to where you want to be in your life.

BILLING AND PAYMENT Your insurance policy is a contract between you and your insurance carrier. You are ultimately responsible for payment-in-full for all services Psyched Solutions, P.A. provided to you. Any charges not paid by your insurer will be your responsibility, except as limited by our contract (if any) with your insurance carrier. Payment is required at each session. The fee for your treatment and other services starts from $75-$2,800 per session. Except for very brief reports or messages, (up to 10 minutes). You will be charged for phone therapy, report writing, FMLA paperwork or other professional services. Many health insurance policies cover the services of psychotherapists. Some insurance coverage requires you to pay only co-pay at your visit Copayments for office visits are due at the time of service; nevertheless, reimbursement varies considerably from policy to policy. Most policies have annual deductibles, co-payments and/or other benefit limits. Read your policy carefully and be aware of what is or is not covered. You may wish to call the member services number on the back of your card to find out the details of your coverage. If you are having difficulty paying your bill, a payment schedule can be discussed. Patients who owe money and fail to make arrangements to pay may be referred to a collection agency.

MISSED APPOINTMENTS AND LATE CANCELS If you fail to cancel a scheduled appointment, we cannot use this time for another client and you will be billed for the entire cost of your missed appointment. After three “NO SHOW” and or excessive late or last minute cancelled appointments, you will be discharged from our practice and we will no longer see you as a patient. A full session fee is charged for missed appointments or cancellations with less than a 24-hour notice unless it is due to illness or an emergency. A bill will be issued directly to all clients who do not show up for or cancel an appointment.

INSURANCE INFORMATION We participate in many but not all insurance plans. It is your responsibility to contact your insurance company to verify that Angela Brinson (Rendering Provider) and/or Psyched Solutions, P.A. participates in your behavioral health plan. Out of network charges may have higher deductibles and copayments. If your insurance carrier pays you directly, you are solely responsible for payment and agree to forward the payment to Baron Counseling Services immediately. If insured, it is your responsibility to ensure that services provided to you are covered benefits and authorized by your insurer. We are happy to answer any additional questions and make alternate financial arrangements if the situation warrants it.

EMPLOYEE ASSISTANT PROGRAMS If you are using your Employee Assistant Program (EAP) to pay for your counselling sessions, you must contact them to obtain a referral to Angela Brinson and/or Psyched Solutions, P.A. I cannot do this for you. You will be given a limited number of sessions. You should be clear on the number of sessions authorized. This counseling is provided at no cost to you; however, if you need continued counseling beyond the number of sessions authorized by your EAP or if you need mental health treatment beyond the scope of the type of counseling provided through the EAP, it will be your responsibility to determine whether or not those outside services are covered under your medical benefit plan and to pay any charges for services not covered by your medical benefit plan.

SLIDING SCALE: As a benefit to those who do not have health insurance, we are happy to offer sliding scale fees (10%-35%) for those who qualify. The amount by which your fees will be reduced depends on your gross income ($30,000 or less). This discount may be applied to copayment, co-insurance, and/or deductible balances if applicable. Sliding scale discounts are offered based upon family/household size and annual income. *Please Note: Proof of income is required for sliding scale discount.

Signature - Practice Policies and Procedures

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Informed Consent and Permission to Perform a Psychological Evaluation

This form provides information about our services and about you and*/*or your child's rights and responsibilities as a client. Your signature at the bottom indicates that you understand the information and freely consent to participate in or allow your child to participate in this assessment. Psychological Testing Through the administration 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 differences and disabilities, academic functioning, or coping styles. Throughout the process you have the right to inquire about the nature or purpose of all tests and procedures. You also have the right to know the test results, interpretations, and recommendations. The assessment generally begins with an informational interview followed by the administration of one or more psychological or educational tests. Although it is sometimes possible to complete the testing in one sitting, it is common for the evaluation to require two or three several-hour sessions.

Psychological Testing

Through the administration 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 differences and disabilities, academic functioning, or coping styles. Throughout the process you have the right to inquire about the nature or purpose of all tests and procedures. You also have the right to know the test results, interpretations, and recommendations. The assessment generally begins with an informational interview followed by the administration of one or more psychological or educational tests. Although it is sometimes possible to complete the testing in one sitting, it is common for the evaluation to require two or three several-hour sessions.

Types of Evaluations

Full Psycho-Educational Evaluation - The purpose of this evaluation is to provide an in-depth study of the cognitive/intellectual processes and current academic levels of functioning. This evaluation might also include an assessment of memory and executive functioning. Psycho-diagnostic Evaluation – The purpose of this is to evaluate for behavioral or emotional factors such as Attention-Deficit*/*Hyperactivity Disorder, depression, or anxiety disorders that may be affecting one's functional abilities.

Other

Types of Measures

Diagnostic Interview and Developmental History - to obtain information about the client outside of the testing situations, and to obtain a comprehensive history in order to make a more reliable diagnosis.
Cognitive Testing - to assess overall intellectual ability, as well as strengths and weaknesses in areas such as verbal comprehension, perceptual reasoning, working memory, and processing speed.
Achievement Testing - evaluation of academic abilities in the areas of word reading, phonics, reading comprehension, written language, math reasoning, calculation, and academic fluency. Measures of oral language may also be assessed.
Attention and Executive Functioning assessment - to assess attentional processes, along with any difficulties pertaining to initiation, sustained effort, emotional modulation, ability to monitor and self correct, working memory, organization, and planning.
Behavior Rating Scales and*/*or on-site behavioral observation at school in order to get a sample of behaviors outside of the office setting
Interviews with teachers, family members, or other relevant individuals. Such interviews will only be conducted with specific written consent.

Other

Feedback The type(s) of feedback you and*/*or your child will receive may include: A comprehensive written report that provides findings for each measure, an integrated summary, and recommendations for accommodations, interventions or treatment. A brief, written summary that provides an overview of findings and recommendations. In-person or telephone interpretive feedback session.

Release of Records

I understand that the information obtained in this evaluation is confidential and will not be released to any person or organization without my written permission. Written records are released only after a consent form is signed by the parent*/*legal guardian or the student if they are 18 or older. The only exceptions to this policy are rare situations in which we are required by law to release information with or without your permission. These include 1) if there is convincing evidence that you are suicidal or homicidal; 2) there is evidence to suspect abuse of children or the elderly; and 3) if the records are subpoenaed by the court. In the unlikely event of any of these situations, we would attempt to discuss the situation with you and limit disclosure of confidential information to the minimum necessary to insure safety.

Signature Informed Consent and Permission to Perform a Psychological Evaluation

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Statement of Rights

STATEMENT OF RIGHTS

Psyched Solutions, P.A. is committed to ensure that you receive professional and humanistic services, directed towards your needs in a manner that protects your dignity and feelings of self-worth. To this end, the following Statement of Rights has been formulated.

CIVIL RIGHTS You have the right to be treated with dignity and respect. You retain all rights, benefits and privileges guaranteed by law. DISCRIMINATION Services will be provided to you and/or your family members without discrimination, ethnic background, personal or social creed, racial membership, sex, religion, or age will not affect our services to you. You will not be refused any services based on lack of, or limited, personal financial resources. Travel and loss of work time will be discussed and kept at a minimum. No physical barriers will preclude treatment. Services will be provided with a minimum waiting time. Agency services hours will be reasonably convenient to all requesting services.

CONFIDENTIALITY Your medical and social service records are confidential and cannot be released to anyone without express consent given by you or your guardian. However, the Court without your permission can subpoena your records, especially if you are court-mandated to treatment. Also, knowledge of child abuse, elder abuse, and intent to harm other or yourself must, by law be reported in addition to knowledge of communicable diseases (e.g., hepatitis). You have the right to review and approve any information being requested by another agency that is providing services to you. You have the right to an individual plan for treatment and will be expected to participate in your plan of treatment. You have the right to know the name and professional credentials of anyone working with you. You may request to participate in any staff meeting regarding yourself. You may review your clinical record upon written request. You will be advised of the positive effect and possible complication of any drugs or medication prescribed by any physician involved in your treatment. You have the right to refuse to participate in or be interviewed for research purposes. You have the right to refuse any electronic and/or visual recording of your treatment without your expressed written approval. You have the right to terminate treatment at any time.

GRIEVANCE PROCEDURE If you feel that your treatment program has not been provided fairly, or reasonably, you may present your concerns, in writing to the supervisory staff. **You have the right to legal recourse; you have the right to confer with family, attorney, physician, clergyman, and others at any time. You may contact the Quality Assurance Coordinator for Baron Counseling Services and express your grievance Or the Department of Children and Families at 954.467.4298 if you have a grievance regarding the treating agency. Your concerns will be given priority consideration. You are under the protection under Florida Statute 491 Section 10E-16004(27) as follows: Protection of Clients – The rights of the clients who are admitted to this program shall be assured and defined in each program operating standards. This shall include operating standards, which protect the dignity, health and safety of clients.

Signature Statement of Rights

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Consent for Participation General

Provider Qualifications Our agency has full staffed professionals that have the education, training and experience in conducting services. You have the right to inquire fully about the credentials, education, and experience of you or your childʼs therapist and to have your questions answered to your satisfaction. At Psyched Solutions, P.A., services are provided by a licensed member (Psychologist, Social Worker or Counselor) or by a master level professional with training enabling him or her to practice under the supervision of a licensed professional.

What to Expect from Services your therapist or childʼs therapist will work to provide the most effective services possible. Studies of counseling indicate that most people benefit substantially from the services and experience improvement in the problem areas for which services were sought. However, substantial benefits, while likely, cannot be guaranteed. Response to counseling is different for each client and should be discussed on an ongoing basis with your childʼs therapist. Therapy can involve a variety of different activities, which vary from person to person. In general, a licensed professional will assess your childʼs areas of concern and then your psychologist/therapist will provide appropriate services designed to resolve or reduce the problems. There may be individual work with your child, discussions with you possibly including way to help your child outside of therapy, testing, and/or family sessions. Therapy and/or Testing may focus on feelings, thoughts, relationships, and/or behaviors. With young children, therapy generally includes play activities used as a means of understanding and communicating with the child. Services may be provided within the homes, school and other places conducive for therapeutic exchange, at times convenient for participants, parents and community resources. We are available days, evenings and weekends as needed. Actual times of services are negotiated between the person served/guardian and therapist.

Family Involvement We at Psyched Solutions, P.A. believe that it is important that the childʼs family is included, as appropriate, in the services the child is receiving. We invite parent participation because we know that personʼs goals and gains are strengthened when the person receives the support of his/her family and these family members can facilitate treatment recommendations outside of the therapeutic sessions. Family involvement is mandated in cases where a minor is being treated unless it is clinically inappropriate for restrict or restricted by the courts of protective service recommendation. Family involvement is highly encouraged when individuals served are adults over the age of 21, as clinically appropriate.

******Confidentiality ******Historically, counseling was associated with complete confidentiality between the family and specialist. Currently, both law and professional ethics require therapists to maintain complete confidentiality in most cases. In these cases, the psychologist/therapist cannot release any information about your family without your expressed written permission. However, as a result of legal developments, there are some exceptional circumstances in which therapists are required to communicate information about therapy to persons outside the family.

Below are some exceptional circumstances in which psychologist/therapist are required to communicate information about therapy to a person outside the family. These exceptions include the following situations:

The participant presents a clear and present danger to himself or herself and refuses to accept appropriate services the participant communicates to the therapist a threat of physical violence against a clearly identified reasonably identifiable victim, or the therapist has a reasonable basis to believe there is a clear present danger of physical violence against such a victim.

The participant introduces his or her mental condition as a defense in legal proceeding.
In child custody or adoption cases, the judge determines that the therapist has information bearing significantly on the participantʼs ability to provide suitable care.
The participant initiates legal action against the psychologist/therapist.
The therapist has grounds to believe a child under the age of 18 or an elderly person (over age 60), or a handicapped adult, has been, or is at risk of being abused or neglected.
The therapist has reason to believe that a child was prenatally exposed to a potentially addictive or harmful drug or controlled substance.
The therapist has reason to believe a health care professional has engaged in professional misconduct.
A judge orders the therapist to release participantʼs information.

It should also be noted that insurance companies reimbursing therapeutic services and/or psychological testing require information about these services. Therefore, if you are using insurance to pay for you or your childʼs services, certain information may be released to your insurer.

I indicate by my signature on the form that I consent to the therapy services and that I understand and consent to the conditions described above. I understand that this consent will remain for the duration of services being provided by Psyched Solutions, P.A.. I also understand that I may revoke this consent at any time.

I am the person who is subject to the health records that will be used or disclosed. I consent to treatment and agree to the use and disclosure of my health information as described in this consent.

I am the parent, guardian, or person authorized to act on behalf of the participant whose records will be used or disclose. I consent to treatment and agree to the use and disclosure of the person served health information as described in this consent.

Signature Participation General

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