Pre-Appt Form

Child/Teen Pre-Appt Packet

By filling out this information prior to your appointment, you will allow the clinician to spend your appointment time better getting to understand your specific concerns. For patients and providers, please note that we do not see children under the age of 9 years old in MA.
Parent Name*
Parent #1 Name

First NameLast Name
Parent #2 Name

First NameLast Name
Parent #1 Phone number*
Parent #2 Phone Number
Parent #1 email
by providing your email, you are agreeing to Clarity contacting you via this method regarding upcoming appts and related correspondence.
Parent #2 email
example@example.com
By providing your phone number and/or email address, you consent to receiving SMS text messages from Clarity regarding upcoming appointments and important information about your testing. Please type "agreed," if you agree below. If you prefer not to receive these messages, please indicate in the box below that you would like to receive communication through our standard patient portal instead by typing "portal only" (please ensure to check your spam folder to avoid missing any messages). To opt-out at any time, reply with "STOP." Standard data rates may apply.
Phone Number: By providing your phone number and/or email address, you consent to receiving SMS text messages from Clarity regarding upcoming appointments and important information about your testing. Please type "agreed," if you agree below. If you prefer not to receive these messages, please indicate in the box below that you would like to receive communication through our standard patient portal instead by typing "portal only" (please ensure to check your spam folder to avoid missing any messages). To opt-out at any time, reply with "STOP." Standard data rates may apply.
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child/Teen Name*
Child/Teen Date of Birth*

MonthDayYear
Date
Child/Teen Gender Assigned at Birth*

MaleFemale
Child/Teen Pronouns*

He/HimShe/HerThey/Them
Preferred Testing Location

North Reading, MAKingston, MATelehealth (for patients residing 25+ miles from our nearest location only + must have strong internet connection and computer purchased after 2022+)
Primary Insurance Plan
Policy/Member ID
Group Number
Subscriber Name

First NameLast Name
Subscriber's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber Date of Birth

MonthDayYear
Date
Patient's Relationship to Subscriber
Secondary Insurance Plan put n/a if not applicable)
Please upload a picture of the front of your insurance card. Image size must be less than 10MB.

Cancelof
Please upload a picture of the back of your card. Image size must be less than 10MB.

Cancelof
Policy/Member ID Secondary put n/a if not applicable)
Group Number Secondary Insurance (put n/a if not applicable)
Please upload a picture of the front of your card. Image size must be less than 10MB.

Cancelof
Please upload a picture of the back of your card. Image size must be less than 10MB.

Cancelof
Insurance Information Notice

Your Responsibilities:

We want to ensure a smooth billing process for your care. Please be aware that you are responsible for:
- Providing complete and accurate insurance information, including any secondary coverage
- Updating us promptly if your insurance plan changes or expires during treatment
- Maintaining current payment information on file
- Verifying your coverage and benefits with your insurance provider
- Important:
Our treatment timeline may extend over several months. We reserve the right to cancel appointments if payment methods are invalid or insurance has expired
While we make every effort to verify your coverage, you remain ultimately responsible for any services not covered by your insurance. Please contact our billing department if you have any questions about your coverage or payment responsibilities. BillingHelp@claritypsychologicaltesting.com
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the provider. I understand that I am financially responsible for any balance. I also authorize the provider and my insurance company to release any information required to process my claims.

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Card Type: Debit/Credit Card Authorization (As of 2023, you are required to have a valid form of payment on file at all times)

VisaMastercardAmexDiscoverOther
I authorize Boodah Inc: DBA Clarity Psychological Testing to charge my credit card for additional services provided to patient, for services not paid by insurance carrier and which are considered concierge services as noted under payment terms and uncovered services. Charges to this credit card may include but are not limited to office visits, phone sessions, paperwork ($15/ page), and late cancellation or no-show fees. I understand my credit card will be automatically charged for these services and I will contact the office prior to my visit if I need to change cards on file. *

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Psychiatric Evaluation Consent : Patient Signature (If over age 14) or Guardian Signature*

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By my signature below, I acknowledge that I consent to a psychological evaluation by Clarity Psychological. That I have been informed of the policies regarding evaluations and have read the consent forms as well the policies regarding late/cancellation and missed appointments; and I agree to all of the payment arrangements outlined in this form. I fully understand my rights and obligations as a client at Clarity Psychological and I freely agree to this assessment.
Acknowledgement of Receipt of the HIPAA Notice of Privacy Practices: Patient or Legal Guardian Signature *

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With my signature above, I acknowledge that I have received this HIPAA Notice of Privacy Practices
Request for Restriction of Uses and DisclosuresPlease restrict the use and disclosure of my PHI in the following ways:
OPTIONAL: Health Care CoordinationPlease click the link below to fill out a Release of Information form (ROI) if you wish to release your records to another healthcare provider, person (including yourself), or organization. An ROI will be required for anyone to call on your behalf or coordinate your care if you are over the age of 18.Confirm as read *

Confirm as read
What are your primary concerns in terms of seeking testing for your child?

ADHDAutismGeneralized Anxiety DisorderMajor DepressionBipolar DisorderPersonality Disorders: Narcissistic PD, Borderline PD, Obsessive Compulsive PD, etc.Learning Disability: Dyslexia, Dysgraphia, Dyscalculia (this is a non-covered expense by most insurance plans bc they don't deem it medically necessary, but we do provide this testing)PTSDCognitive ImpairmentSocial impairmentBehavioral issues/defianceanger/irritability
If you are concerned about ADHD, please check what is specific to your concerns about your child/teen?

lack of motivationprocrastinationimpulsivityfidgetinghyperactivityinterrupting othersdifficulty staying with one train of thoughtdifficulty completing tasksforgetting multi step instructionsoccupational or relational impairment
Beyond what you checked above, what other things would you like testing to address? (what to focus on in therapy, what type of therapy to engage in, issues with occupational impairment, social impairment, motivation, etc.)
Do your child have any history of trauma (early neglect, physical or sexual abuse, violence, etc)? Does this come up for them in the form of nightmares? flashbacks? avoidance in present day?
Any severe symptoms in terms of self-harming behavior or suicidal ideation?
Please elaborate on any mood or behavioral concerns your child/teen might have (won't get out of bed, isolating, mood swings, defiant, paranoia, psychosis, grandiosity, no remorse, tantrums, poor social skills, irritability, excessively tearful, worried, etc.)
Have they ever incurred any head injuries? Concussions? Loss of Consciousness? MRI's performed? Bleeding or abnormalities found?
Any disordered eating concerns? Picky eater, binge eating, purging, orthorexia, over-compensatory exercise, over-restriction?

Anorexia NervosaBulimiaPicky eaterOrthorexia (disordered eating under the guise of "healthy or clean eating"Binge eatingPurgingChew and spitOver-compensatory exerciseEmotional over eating
How is your child's sleep? Do they require anything to fall asleep (melatonin, white noise, sleeping medication) Is it hard to stay asleep? fall asleep?
What have they tried already ? (self help books, therapy, OTC supplements, exercise, meditation, yoga, church, etc.) Was there anything that seemed particularly effective?
Has your child currently, or have they ever seen a therapist or psychiatrist?, If so, please include their names and how long ago.
Have they tried or are currently taking any psychotropic medications (zoloft, prozac, ambien, abilify, depakote, wellbutrin, propanolol, alprazolam, etc)? If so were there any ones that were particularly effective or caused adverse side effects?
Have they ever been diagnosed with any medical conditions and if so, what medications do they take?
Any history on maternal or paternal side for mental health issues (bipolar disorder, adhd, depression, suicide, ocd, etc.)
Pregnancy and Delivery: Any complications during pregnancy or delivery (NICU, substance exposure in utero, pre-eclampsia, etc).
Did your child/teen meet all developmental milestones on time (walking, talking, potty training, etc.)
Are they involved in any extracurricular activities, sports, hobbies?
Has your child ever worked with an allied health therapist (speech therapist, occupational therapist, physical therapist)?
Family & Social History
Please describe your living situation? Is there anyone in the home besides you and your child? siblings? step brothers/sisters? grandparents? roommates?
Any major changes in the family? Loss of a job? Moving homes or schools? divorce? separation? passing of a close family member? etc?
If parents are separated or divorced, please describe the custody/living situation. Please note both CA and MA law: In the case of minor children, parents must provide consent for treatment. In the case of shared or joint, legal custody of a child by divorced parents, the consent of one parent is required to proceed, however the other parent must not state a clear objection. If you are the parent who is bringing your child in for appointments, you may be asked for the divorce decree, legal/medical custody agreement, name, address and telephone number of his or her other parent. As a routine matter, both parents will be invited to participate in your child’s treatment. The exact form and frequency of such contacts will be determined on the basis of need as assessed on a case-by-case basis by your child’s doctor or therapist. When one parent objects, treatment cannot proceed. In order for treatment to proceed, parents must resolve the matter between them, or refer the matter to the court for resolution.This consent will remain in effect through completion of your treatment or evaluation with Clarity. You have the right to revoke your consent at any time. Should you choose to do so, we ask that you do so in writing. Notice of revocation of consent will be considered effective on the date your doctor receives your revocation. If there is any pertinent information for us to know - please state below, otherwise just put n/a
Please note if custody is shared. Each parent may be asked to complete paperwork and whether they would like to be involved in the process or at least have no clear objection to having their child tested. Additionally, in an effort to ensure all parties are on the same page, we only offer one intake and one feedback session. We do not provide separate sessions for each parent.*

N/A Not applicable, no shared custody arrangementProvided other parents info aboveOther
Any legal issues or mandates related to your child/teen?
What would you say are your child/teen's best strengths and qualities?
Does your child/teen have any difficulties initiating or maintaining friendships with others? volatility or "drama" in relationships?
Social Media: How many hours would you say your child/teen is using social media per day right now and which type? linked in? instagram? tik tok? youtube?
What have you told your child about why we are testing? It is important that your child sees this as an opportunity to learn how they learn or learn about how they see the world vs. seeing the testing as being due to something being "wrong" with them.
Educational History
Any upcoming or prior testing at your child's school? It is important for us to know this because certain tests can't be repeated in terms of administration within one year of each other or it can render the results invalid.
Please name the school your child is currently attending and what grade they are in. Please also indicate if they have ever been held back a grade and if so which grade.
Name of School
Please provide any relevant information related to your concerns regarding your child and their academics (teacher concerns, 504, IEP, behavior concerns, defiance, homework
Thank you so much for taking the time to complete this questionnaire! Please use the space below to tell me anything else that is important for me toknow about your child or teen.
Medical Records & Office Hours
We are required by law, to keep complete medical records. Most of our medical records will be electronic, encrypted. Any written records including the initial consent forms, letters, outside medical records, will be kept locked. You are entitled to review your medical record at any time, unless we feel that by viewing your records, your emotional or physical well-being will be jeopardized. If you wish to view your records, we recommend that we review them together to minimize any confusion or misinterpretation of medical terms. Time spent collecting, printing, copying, and summarizing the medical record will be charged the appropriate fee. We understand that at times, various forms or letters may be required to assist you with your healthcare needs. Clarity staff can complete forms and write letters as necessary upon request, assuming they do not put the clinician in dual roles or challenge ethical guidelines. Please allow 3-5 business days for completion of requested forms/letters. There may be an additional fee assessed for completion of forms as most insurance carriers do not cover this additional service. Our office is available Monday-Friday 9:00 am - 5:00 pm and may be reached via text at 617-982-2129 or by email at support@ClarityPsychologicalTesting.com. Our providers are NOT available after hours and some providers may have an alternate working schedule. If you need any further information before your appointment or have questions regarding an appointment, please use our secure portal to message our practice or call during regular business hours. We are contracted with most insurance companies and have a contracted rate we accept. However, it is your responsibility to verify coverage and deductibles with your insurance company prior to consenting to services.

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Services
PSYCHOLOGICAL TESTING:Overview of Process:Our testing occurs in three easy appointments: 1) the intake appointment where you provide info to the clinician first. Intake appointments can be quick and to the point if there are only a few concerns or they can span a full 45 minutes. 2) the testing appointment (in person) this can be a 4-6 hour day when you come to our office for testing with our psychometrist. 3) the feedback appt.: this is where the clinician goes over the results of your testing with you, what was ruled in, what was ruled out, and treatment recommendations. General info: The pre-screening form will be used as initial history. A provider at Clarity will ask for additional information during your initial intake. Please send to support@claritypsychologicaltesting.com or upload any previous neuropsychological test results, school testing results, and/or pertinent records to the patient portal before your initial appointment. We reserve the right to decline a testing case for any reason if we feel it is not a good fit for our practice. At this time, Clarity does not administer the ADOS-2, which is often a requirement of many programs to recognize an Autism diagnosis. However, we are able to screen for Autism in conjunction with testing for other diagnoses such anxiety, depression, ADHD, if you are just questioning it. Misrepresentation: We do not perform evaluations that would be considered falling outside of "medical necessity," as deemed by your insurance carrier. These often include evaluations that are court ordered, forensic, adoption, surrogacy, disability, custody, capacity, competency. You also may be waiving your right to testing by a forensic psychologist (specialist) once you’ve had testing done in our office. We are not specialized or trained to testify in a forensic setting, therefore, this could possibly hinder your chances of winning your case or obtaining disability benefits. You are signing below that if you misrepresent your reasons for wanting testing or are not clear that you are needing testing for reasons outside of pure diagnostic clarification; you will be responsible for the entirety of our fee at the standard rate (not the contracted insurance rate) as well as any travel and/or legal consultation fees incurred as a result of your case. Final Report: Once your full out-of-pocket responsibility has been met, we continue processing your finalized report. Therefore, please make sure your payment is up to date and complete for the quickest turnaround and efficiency of your results. Psychotherapy, or talk-therapy, is a powerful treatment for many mental complaints. It offers benefits of improved interpersonal relationships, stress reduction, and a deeper insight into one’s own life, values, goals, and development. It requires a great deal of motivation, discipline and work on both parties for a therapeutic relationship to be an effective one. Clients will have varying success depending on the severity of their complaints, their capacity for introspection, and their motivation to apply what is learned outside of sessions. Clients should be aware that the process of psychotherapy may bring about unpleasant memories, feelings, and sensations such as guilt, anxiety, anger, or sadness, especially in its initial phases. It is not uncommon for these feelings to have an impact on current relationships you may have. If this occurs, it is very important to address these issues in session. Usually, these unpleasant sensations are short lived. At your initial visit, your provider will conduct a thorough review of your current complaints and of your background. One of the most important curative aspects of a therapeutic relationship is the goodness-of-fit between therapist and client, so, the initial visit is also your opportunity to determine for yourself if the therapist you’ve been matched with is the right provider for you. If you feel that the therapist is not well matched to your needs, we would be happy to provide you referrals to other mental health professionals. Frequency and Durations of Psychotherapy Visits: Your initial consultation visit will decide together the structure of your therapy. If you are to undertake psychotherapy, we find that weekly 45-60-minute sessions will provide the best results. We may discuss an alternate treatment structure depending on your circumstances.

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Confidentiality
The security of your sensitive information is of utmost importance to us, and we are bound by law to protect your confidentiality. Any disclosure of your treatment to others will require your explicit written consent. As described above, basic information about your treatment may be disclosed to your insurance company for purposes of prior authorization or claims payment if necessary.There are exceptions to this confidentiality, where disclosure is mandatory. These include the following:• If there is a threat to the safety of others, we will be required by law to take protective measures including reporting the threat to the potential victim, notifying police, and seeking hospitalization.• When there is a threat of harm to yourself, we are required to seek immediate hospitalization, and will likely seek the aid of family members or friends to ensure your safety.• If a mental illness prevents you from providing for your own basic needs such as food, water, shelter, we will be required to disclose information to seek hospitalization.These situations rarely occur in an outpatient setting. If they do arise, we will make our best effort to discuss any action plan with you. However, some instances may require action without prior notification. In rare circumstances we may find it helpful to consult with other professionals specialized in such situations (without disclosing your identity). If you are a minor, your parents may be legally entitled to some information about your therapy or testing. We will discuss with you and your parents’ what information is appropriate for them to receive and which issues are more appropriately kept confidential.

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Teaching Facility
Our practice is a teaching facility and as such implements the use of psychometrists, trainees, and graduate level interns who often require supervision and feedback. We employ various technologies to be able to periodically monitor our employee and Independent Contractors (IC’s) performance to ensure quality control and standardization of test administration protocols. In this vein, some or all of your session may be electronically recorded for training and educational purposes. All employees and IC’s of Clarity have signed a Business Associate Agreement, which prohibits them from releasing or sharing any PHI pertaining to our clients with outside parties unless required to by law.

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No Show & Cancellation Policy
I understand that I am responsible for keeping track of my appointment times and dates.I understand that I am responsible for contacting the practice 48 hours prior to my appointment if I need to cancel or change. It is ultimately my responsibility to know when my appointments are scheduled.If you cancel the same day or do not show up to your appointment then you will be automatically charged a $150.00 fee for telehealth appointments and a $300.00 fee for in person testing appointments. If this fee is not paid or credit card on file is declined your appointment will not be rescheduled.When the office is closed there is a voicemail set up for you to leave a message. If an emergency happens that is outside of your control that prevents you from appearing at your appointment at the scheduled time you can request the fee to be waived. Excessive no shows or cancellations may result in termination of services.By signing this form, you agree to commit to your appointment or cancel with more than 48 hours' notice or otherwise be subject to a fee.NO SHOW/CANCELLATION FEES ARE NONREFUNDABLE AND NOT BILLABLE TO INSURANCE

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Consent to Treatment and Practice/Privacy Policies
By signing below, you certify that you have read and understand the terms stated in this form. You indicate that you understand the scope of our services, session structure, fees, payment policy, insurance reimbursement, confidentiality, the nature of our practice, and contact information, and that you agree to abide by the terms stated above during the course of our relationship.If prior authorization is required Clarity may need to provide information about your diagnosis, history, and treatment plan to your insurance company. Once this information is provided, it will be subject to the privacy policies of the insurance provider and is out of our control. Any co-payments and/or outstanding balances are your contractual responsibility and payable to Clarity at the time of your visit for copays and immediately after your visit for any outstanding balance. It is your responsibility to inform Clarity of any changes to your insurance during your evaluation process. If you do not notify Clarity of any changes to your insurance in a timely manner, you understand that you are liable for any charges for services not covered by your insurance.

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Please upload a copy of the front of the insurance card(s) you would like to use for your services Please make sure the image is not blurry. *
Please upload a copy the back of the insurance card(s) you would like to use for your services. *
Subscriber's Name

First NameLast Name
Subscriber's Date of Birth

MonthDayYear
Date
Please check the boxes to select the permissions you grant to Clarity Psychological Testing in regards to transmission of information between your treatment team. You may select one or more as applicable.

Consent to Send: I consent for Clarity Psychological Testing to send assessments, input forms, and other relevant documents to the therapists, teachers, and allied health professionals I designate:Consent to Receive Information: I also consent to the above-named parties releasing information related to myself or the patient (if I am the guardian) to Clarity Psychological Testing.Consent to Release Reports: I consent to allowing Clarity Psychological Testing to release my assessment reports and related documents to the individuals I designate:
Designated Recipients to Send Information:Name and Contact Information
Designated Recipients to Receive Information: Name and Contact Information
Designated Recipients for Report Release: Name and Contact Information
Liability Release and HIPAA AuthorizationBy signing below, I release Clarity Psychological Testing from liability related to the authorized release and receipt of my protected health information as outlined above. I authorize Clarity Psychological Testing to transmit this information as necessary within the confines of Federal HIPAA regulations.

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Should be Empty:

Child/Teen Pre-Appt Packet

Family & Social History

Educational History

Medical Records & Office Hours

Services

Confidentiality

Teaching Facility

No Show & Cancellation Policy

Consent to Treatment and Practice/Privacy Policies