INFORMED CONSENT
(PSYCHOLOGICAL SERVICES/TESTING, CONFIDENTIALITY, PAYMENTS, CANCELLATIONS, AND WITHDRAWING)
1. I understand telepsychology refers to remote psychological services including data collection, counseling or education via videoconferencing, emailing, phone conversations, and any digital sharing/communication. If texting is used, no personal information will be shared, and it will be for booking, reminders, or requests for info (this could occur if client has not been reachable via email or phone). I can personally request additional information via text if I wish, not withstanding that I can also do this via email or phone.
2. Only the psychometrist/ psychologist (examiner) will consult with me and/or my family member, and the data will be stored confidentially on the examiner’s computer. A billing person will have access to data as/if needed. None of the data will ever be shared with additional parties without parental/child consent. All data and including history, documents, reports, will be on examiners’ computers and HIPPA approved secure servers (JaneApp, Q-Global) accessible by Dr. Laurie Cestnick, Ph.D., C. Psych (licensed in Massachusetts and Connecticut), and occasionally a psychometrist or billing person.
3. I understand that psychometrists and psychologists offering telepsychology services are in Massachusetts or Connecticut (occasionally in Ontario under limited circumstances and I will be informed should this ever happen) and are governed by regulations outlined by the Massachusetts/Connecticut Boards of Registration of Psychologists as well as best practices for remote services and remote testing outlined by creators of test materials that may be used.
4. While telepsychology will be conducted primarily through secure and private means (Zoom for Medical), I understand there are always some risks with telepsychology services including but not limited to: transmission of personal information could be disrupted or distorted by technical failures, or intercepted, or accessed by unauthorized persons.
5. Sensitive documents requiring signature will be sent via email or JaneApp unless requested to be sent differently (e.g. Docusign). Some questionnaire data will be sent via Q-Global to your email
CONSENT TO PSYCHOLOGICAL ASSESSMENT/TESTING
Remote:
By signing this consent form, I agree to remote psychological testing (completion of questionnaires and/or neuropsychological/psychological test batteries) of myself and/or my child, in part or in full (case-by-case determined).
I understand that for interviewing, I am minimally required to have a phone, and for remote testing to take place, a good internet connection, computer or tablet, and a private room with adequate lighting (free from distractions) is required. The psychometrist/psychologist will inform me of any additional conditions for my assessment (determined on a case by case basis).
This remote assessment will largely involve interviewing/talking, and completing questionnaires on my computer screen at home (clicking on URL links in emails sent to me, that automatically open
questionnaires on my screen that I fill out, and when done, the data is automatically sent back to a system for the examiner to retrieve). Occasionally, attention and/or cognitive testing can be completed remotely if dire reasons exist to do so, e.g. to qualify for or enter treatment/rehabilitation programs or to examine possible changes from recent trauma or brain insult. Caution is taken in the interpretation of such data given that some tests were not originally created for online use. In such instances, consideration should be given to re-doing some tests in person when it is possible to do so.
Many of the tests that we use for remote testing were designed and tested for the purpose of remote testing, and others have been approved for online use by the creators/distributors of the tests in lieu of COVID-19 and approvals are still in place. In the latter case, the responsibility is placed with the clinician to use good clinical judgement and skill in the administration and later interpretation of findings given person and context-specific limitations that may arise during assessments. Some or all tests administered may render reliable findings from which to draw diagnostic inferences, and this is determined on a case-by-case basis given outcomes from each assessment (noise, rapport with clinician, ability to attend to the screen, quality of internet, presence of any other parties, etc.).
In-person Testing:
:
I (adult) or my child will be sitting at a desk and given supplies and/or stimuli from computers/books along with instructions as to how to perform tasks. In the case of ASD diagnostic rule outs, moderate to severe TBI, dementia, or assessments of small children (observations during structured play) may also occur with a family member, guardian/parent present. For young children, a parent may be expected to be included in the play upon direction of the psychologist. Testing generally starts at 9am (unless otherwise determined), breaks are given minimally on the hour and lunch is at noon for up to 1 hour. Testing generally will not go beyond 3pm due to the tendency for people to fatigue, and small children or those with TBI/fatigue may need more sessions to complete tasks. Individual differences dictate the number and level of breaks and testing days required. If my child is being tested, I can stay and wait in the lounge room with access to WiFi, desk, couch, and drinks. Parents are expected to pick their children up at noon to take them out for lunch or they can wait with them and eat lunch in the building.
CONSULTATIONS OR COUNSELING
I understand the I can cancel without penalty 24 hours prior to the appointment. Cancellations will rendera charge of 50% of the hourly rate (typically 50% of $250, making this $125. late fee).
PAYMENT for TESTING/ASSESSMENT
For testing, I understand that there is a deposit of $500. required, and $1000. if Dr. Cestnick must travel from Canada for the testing. The remainder of monies owed are to be paid on the day of testing (full cost ofcall testing is due on the first day of testing). Deposits will be returned if I cancel within 48 hours of the testing appointment. If Dr. Cestnick is traveling from Canada for the appointment, the deposit will not be refunded. Payments can be made via most credit cards, Zelle, or VENMO. When credit cards are used there is a processing fee. I understand I will be provided with a Receipt(s) to submit to my insurance company upon my request; these will be itemized to include diagnostic and CPT codes, fees paid or unpaid, dates for these, NPI, and of course your identifying information (name, birth date, address), etc. I understand that I am responsible for fees in full irrespective of insurance outcomes. As an example, if I/provider were informed by me/my insurer that insurance covers a service when it is later learned that it does not, I am still responsible for the bill and/or any withdrawal fees as outlined below (this can happen if incorrect information is provided by an insurer, a deductible is not paid to the insurer leading to lack of coverage, or other reasons). Staff can assist me with billing/claims for my insurance on occasion upon request, but I am responsible for the bill in full regardless of insurance outcomes
WITHDRAWING AND CONFIDENTIALITY
I understand that I can discontinue neuropsychological/psychological/educational testing at any time. If testing has started and then discontinued, billing will be charged by the “half day” at $2500 for a half day (1 min to 3 hours), followed by $2500 for the second half of the day (3+ hours). Any additional charges related to administration/billing/collection would also be owed, e.g. for billing services, data entry, letter writing/mailing, legal work/time associated with collections, other.
All the information that I provide to the psychologist/psychometrist is confidential and will not be shared with anyone beyond the psychometrist, Dr. Laurie Cestnick, unless one of the following occurs:
- I request that my information be shared with specific persons or parties.
- I share information suggesting that I am at risk of physically harming myself or others.
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I have a disability, am a minor, or am an elderly person who is being abused or neglected by another person or persons;
I have a child who is being abused or neglected; or I share information regarding the abuse of someone who is disabled, a child, or elderly.
- I become a missing person and sharing information may help find me or my child.
- If there is a defense in lieu of complaint toward the provider, as needed with the least harm to the patient.
- A court orders the sharing of records for a trial.
- An insurance company requests notes under regulations associated with potential fraud.
- Dr. Cestnick is audited by a psychology board, and files may be reviewed for quality assurance.
WITHDRAWING AND CONFIDENTIALITY CONTINUED
- I inform that a member of a registration health profession has abused me or my child.
“Dr. Cestnick has explained to me what we will be doing, that what I share will not be shared with anyone unless any of the above things happen, and that I can stop participating at any time. My consent is voluntary and free (not against my will).”
