Consent for Psychological Testing
I, agree to undergo psychological and/or psychoeducational testing administered by Kimi Walker, School Psychologist (from hereon, referred to as Kimi Walker or school psychologist). 
 
I, with the understanding that I have the legal authority to grant consent for such psychological/psychoeducational testing service on behalf of myself (from hereon, referred to as “testing subject”), agree to undergo psychological testing administered by Kimi Walker.
 
I have read, understood and agreed to the following statement as the conditions under which I have given this consent. I also understand that with written notice, I can revoke this consent at any time.
 
I understand that the testing process involves the completion of a variety of psychological and/or psycho-educational assessment instruments and personal interviews. The total time of the evaluation may vary and will depend upon the questions I or the testing subject or the referral source who made the testing referral might have. I understand that I or the testing subject may experience emotional distress because of the personal nature of some of the information solicited by the testing process. I or the testing subject may interrupt or discontinue this testing process at any time.
 
After the testing process is completed, a report based on the results of the testing and information provided by me or the testing subject and others will be written. Unless I indicate otherwise in writing to the school psychologist, this report will be given to the person or agency who referred me or the testing subject for this service and a copy of this report will be kept in the testing subject’s treatment record in custody of Kimi Walker. 
 
Recordings and Technology 
Even with appropriate security, use of computers, the Internet and other electronic forms of communication (e.g., fax, email, cell phone, voicemail, text messages, online scheduling, etc.) have risks that may compromise confidentiality. By signing this consent, you agree to allow the clinicians to audio record testing sessions if necessary, for evaluative purposes. The clinicians agree to store those recordings in a secure way. Additionally, the clinician may electronically record school meetings on behalf of the client to ensure there is an accurate record. 

Limits of Confidentiality: Like all treatment records, reports and results of psychological testing are confidential and can be released only with a written consent authorizing such release. However, I understand if I or the testing subject discloses information related to suspected threats of physical harm of self or others, occurrence of child, elder, or dependent adult abuse, or if commanded by court order, Kimi Walker will be required to disclose such information to appropriate authorities or parties mandated by law.