SAP EVALUATION: INFORMED CONSENT Andy Martin, LPC, MAC, SAP
I understand that there can be no assurance of outcomes regarding evaluations which I have solicited, requested, or have been scheduled for me. I acknowledge that the outcomes of my assessment greatly depend on honestly and truthfully reporting my history to Andy Martin, and I agree to provide accurate and truthful information to Mr. Martin.
Confidentiality: State law and professional ethics require licensed clinicians to maintain confidentiality except for the following situations:
1) I (the client, or legal guardian) give Mr. Martin written authorization to release specific information to specific parties. I understand that I may revoke my authorization to release my information at any time by notifying Mr. Martin in writing. I understand that if my evaluation is mandated by a judicial entity or regulatory board (e.g. a judge for parole or probation services, a drug-free workplace governing body, or a licensing board) then Mr. Martin will not perform the evaluation for purposes of my 3rd party requirements without written permission to share information regarding the evaluation or recommendations with appropriate parties. No information regarding my evaluation, whether written or verbal, will be shared without my written consent – except as described in items 2 through 5 below.
2) If there is suspected child abuse, elder abuse, or dependent adult abuse.
3) A situation in which serious threat to a reasonably well-identified victim is communicated to Mr. Martin.
4) When threat to injure oneself or to attempt/complete suicide is communicated to Mr. Martin. If Mr. Martin believes that a client’s risk of harming oneself or harming someone else is significant and poses a possible safety risk, Mr. Martin may request that other parties become involved in the client’s therapy, including but not limited to client’s family member(s), client’s friends/support system, law enforcement officers. A client’s refusal to allow these safety measures may result in Mr. Martin terminating treatment and referring the client to another provider.
5) The event of a subpoena or the order of a judge to release information.
The assessment process generally involves an interview which may be followed by the administration of one or more inventories. Time constraints and scheduling may require you to return for another session to complete the assessment. Once information has been gathered, the data will be analyzed and a report will be written.
Mental Health and/or Substance Abuse/SAP Evaluations typically include questions involving Background Information and an account of applicable Precipitating Event(s), Substance Use History, Medical History, Mental Health History, Substance Abuse/Mental Health Treatment History, Alcohol/Drug Screening Data, Interviewing Collateral Individuals, Questions Regarding Environmental Risks, the use of a standardized questionnaire (Substance Abuse Subtle Screening Inventory or SASSI-4).
I understand the outcome of my evaluation and any recommendations that I authorize Mr. Martin to communicate to 3rd parties may have what I consider to be adverse effects in my personal and professional life. I understand that whatever personal needs I may have regarding employment, income, legal entanglement, child custody, etc. DO NOT supersede the importance of ethical and necessary recommendations connected to my evaluation.
I understand that as of January 6, 2020, Mr. Martin is required to report the following information on the Federal Motor Carrier Safety Administration: date my initial assessment is completed, date I am eligible for return-to-duty testing. This may not apply if I do not hold a Commercial Driver’s License.
I understand that fees are due when the service is provided. I agree to pay Mr. Martin at the current rate for his services. The fee for SAP evaluations is $450. I understand that my rights to privacy are forfeited if Mr. Martin must turn my account information over to a collection agency because my account is in arrears. I understand that Mr. Martin will not release any evaluation report, data, or other requested correspondence until he is paid in full for services rendered. I understand that Mr. Martin’s fee for an evaluation does not include fees/costs for whatever treatment or education that may be recommended.
I understand that Mr. Martin does not file insurance claims for evaluations required by an employer, licensing or governing body, or court ordered evaluations, including DOT/SAP evaluations. I understand that Mr. Martin does not file claims to Medicare or Medicaid. Mr. Martin accepts cash, check, debit/credit cards, Venmo, and PayPal as payment for services rendered. I understand that if I choose to use a debit or credit card, I will be charged 2.65% of the fee plus 15 cents. Checks written for insufficient funds will result in charge of $50, and your ability to use checks in the future will be forfeited.
If I believe it necessary to subpoena Mr. Martin, I would be responsible for his Court/witness fees in the amount of $1,000 for one-half (1/2) day to be paid five (5) days in advance of any court appearance or deposition. Any additional time I spend over one-half (1/2) day would be billed at the rate of $250 per hour plus travel expenses.
Electronic Communication and Social Media: I understand that Mr. Martin will not communicate with me for any reason by means of electronic mail, text message, or social media (Facebook, Twitter, etc.). I understand that this is to protect my privacy and safety. Requests for appointments and general information may be made by way of Mr. Martin’s website (www.andymartinlpc.com); however, this option may never be used to communicate any information that should be covered in a face to face assessment. Mr. Martin may send me a text message to remind me of an appointment time ONLY.
Cancellations and Missed Appointments: I understand that I am responsible for all regularly scheduled appointments. Should it be necessary for me to cancel an appointment, I realize I must do so at least 24-hours in advance in order to waive the appointment fee. I understand that the fee for any and all missed appointments will be due in full before any further appointments will be scheduled for the client or client’s dependents. I understand that Andy Martin will not bill your insurance for missed sessions.
I understand that if I have a grievance or complaint about my services that I am welcome to bring these concerns the attention of Mr. Martin. If after discussing my issue(s) with Mr. Martin I need to voice further concerns, I acknowledge that I may do so by contacting the office of the Georgia Secretary of State, Licensing Division. http://www.sos.ga.gov/plb/ or call (478) 207-2440.
I understand that have the right to question Andy Martin about his professional qualifications and credentials:
Master of Science Degree in Clinical/Counseling Psychology, Valdosta State University, May 2000
Master Addiction Counselor with National Association for Alcoholism and Drug Abuse Counselors (NAADAC)
Licensed Professional Counselor (LPC) GA Lic No. 4011
Substance Abuse Professional; (SAP)
Member: Licensed Professional Counselor Association of Georgia
This agreement constitutes the entirety of our professional contract. Any changes must be signed by both parties. I have a right to keep a copy of this contract. If you have any questions at all about this agreement, please ask Andy Martin to help you understand them. By my signature below, I acknowledge that I consent to an evaluation by Andy Martin, LPC, that I have been informed of the policies regarding evaluations and have read the 2-page consent form, and that I agree to all of the arrangements outlined in this form. I fully understand my rights and obligations as a client, and I freely agree to this assessment.