BonPsy Child/Teen Pre-Appt Packet

By providing the contacts above, I authorize BonPsy Wellness and its clinicians to reach out to them on my behalf to gather collateral information that might be helpful when conducting my evaluation. 

To enhance your evaluation and support the prior authorization process, you’re invited to submit a 3–5 minute video sharing more about your current concerns. While this step is completely optional, it can be especially helpful in guiding your clinician’s understanding—particularly for complex or nuanced conditions such as Autism Spectrum Disorder, where visual observations may offer additional insight.

Your video will remain confidential and will only be reviewed by our clinical team as part of your assessment process.

What to Talk About
You may use the prompts below to guide your recording. Don’t worry about being perfect—speak naturally, and focus on sharing your experience:

1. Your Main Concerns
What prompted you to seek psychological testing at this time?
Are there particular areas of concern, such as mood, memory, attention, or behavior?

2. Your Symptoms
How would you describe the symptoms you’re experiencing?
When did they start, and how have they changed over time?
How often do they occur, and how intense are they?

3. Impact on Your Life
How are these symptoms affecting your daily life (work, school, relationships, routines)?
Have you made any lifestyle changes or accommodations in response?

4. What You’ve Tried
Have you pursued therapy, medication, or other interventions?
What has been helpful or not helpful so far?

5. Your Goals for Testing
What are you hoping to gain from this assessment?
How might a clear diagnosis or treatment plan change your life?
Are there specific outcomes you’re looking for?

Recording Tips
Choose a quiet, private space to record.
Make sure your face is clearly visible, and speak naturally.
Keep the video to 3–5 minutes in length.
There's no pressure to be polished—this is just for our clinical context. On macs, pressing command + shift + 5 will bring up your QuickTime. For PC's with windows: search for the camera app.

How to Submit
You can submit via the upload feature above, via email (support@bonpsywellness.com), or if you have trouble or prefer not to submit a video, that’s absolutely okay—this step is optional and will not impact your care.

If you have questions or need support, contact us at support@bonpsywellness.com

Important Notice About Insurance: 

I understand that BonPsy Wellness will make every effort to verify my benefits and coverage. However, this is not a guarantee of coverage or payment. I also understand that it is my responsibility to update my insurance information with BonPsy if it changes during the testing process, and failure to do so may result in owing part or all of the testing costs. 

Medical Records & Documentation Policy

At BonPsy Wellness, we are legally required to maintain complete and accurate medical records for all patients. The majority of these records are stored electronically in secure, encrypted systems. Any paper records—such as intake forms, consent documents, or correspondence from outside providers—are stored in locked files to protect your confidentiality.

You have the right to review your medical records at any time. However, if we determine that doing so may compromise your emotional or physical well-being, we may recommend against independent access. In such cases, we encourage reviewing the records together during a scheduled appointment to ensure clarity and prevent any confusion due to medical or psychological terminology. Please note that time spent retrieving, printing, summarizing, or copying your records may incur an administrative fee.

We understand that you may occasionally need documentation—such as letters or forms—to support your healthcare, school, or employment needs. Our team is happy to assist, provided the request does not create a dual relationship or violate ethical guidelines. Please allow 3–5 business days for the completion of such requests. Additional fees may apply, as most insurance plans do not cover this service.

Our administrative team is available Monday through Friday from 9:00 a.m. to 5:00 p.m. You may reach us at (617) 982-2129 or email support@BonPsyWellness.com Please note that clinicians are not available outside of scheduled hours, and some may work on alternate schedules. For non-urgent questions or requests, we encourage you to use our secure patient portal for the most efficient communication.

Our Commitment to Ethical, Evidence-Based, and Secure Care

BonPsy is committed to delivering high-quality, ethical care using a combination of professional clinical judgment, evidence-based practices, and modern technology, including select uses of artificial intelligence (AI). This document explains how AI and video recordings may be used in your care and outlines your responsibilities as a patient, especially when insurance is involved.

Use of AI in Documentation: Scope and Protections

We may use HIPAA-compliant AI technologies in limited ways to improve efficiency and accuracy. These tools may assist with note-taking, data organization (e.g., tables or summaries), and streamlining documentation. AI does not replace clinical decision-making—our licensed clinicians personally review and finalize all reports and recommendations.

We only use AI systems from vendors that have signed Business Associate Agreements (BAAs), ensuring compliance with HIPAA privacy and security rules. All personal data is de-identified before AI tools are used, and our systems do not contribute data to public AI models.

Benefits of AI-Assisted Tools:

Improved diagnostic clarity through pattern recognition
Workflow support (e.g., summarizing data, reducing clerical burden)
Patient-friendly reports (e.g., clearer language and formatting)
Reduced human error under high workload or burnout conditions

Limitations:
Even with safeguards in place, AI-generated content may occasionally contain errors or omissions. For this reason, every output is carefully reviewed and verified by your licensed clinician prior to being finalized or shared.

Quality Assurance Measures

To maintain the highest standard of care, we implement the following safety protocols:

Cross-checking AI outputs with human review
Ongoing training for our team on emerging AI practices
Real-time review and correction of discrepancies

Use of Video Recordings (Training and Supervision Only)
As a teaching practice, we may occasionally record brief video clips (5–8 minutes) of your intake session. These are used strictly for:

Clinical review by supervising psychologists
Training of pre-licensed clinicians or interns under direct supervision
Recordings are stored securely, accessed only by authorized personnel, and never used for marketing or shared outside of the organization.

Insurance Billing: Truthful Use and Patient Responsibility

Your psychological evaluation may be covered by insurance only if it is medically necessary—that is, if it is being used to clarify a mental health diagnosis and/or develop a treatment plan.

⚠️ Important:
If you are seeking testing for other purposes (e.g., academic accommodations, legal proceedings, custody cases, disability evaluations), your insurance may consider it non-covered. Misrepresenting the reason for testing or omitting key information can result in a “clawback” or retroactive denial of coverage.

By signing below, you acknowledge that:

You understand the importance of full transparency when sharing the reason for your evaluation. You may be financially responsible for the full cost of testing if your insurance denies the claim for not meeting medical necessity guidelines.

Understanding Delays and Operational Limitations
We strive to provide timely evaluations. However, delays in scheduling, feedback, or report delivery can occur due to high administrative burdens, insurance coordination, and staffing challenges. These are not fraudulent practices but reflect common systemic pressures in managed healthcare environments.

We are actively improving our processes to minimize these delays and appreciate your patience.

Alternative Private-Pay Options
If you require faster turnaround or services not typically covered by insurance, we can refer you to private-pay providers who offer expedited testing (typically between $4,750–$10,600). These providers operate outside of insurance constraints and can often accommodate urgent needs more quickly.

Confidentiality and Public Reviews
We are committed to respecting your privacy, and we expect the same in return. If you choose to publicly share information about your care (e.g., via social media or online reviews), you waive certain confidentiality protections. In such cases, we may respond publicly to correct misinformation while still upholding professional and legal boundaries.

Your Choices and Consent
We understand that not every patient will be comfortable with the use of AI tools or video recordings. You have the right to:

Consent and proceed with care at BonPsy
Decline consent and request referrals to other providers
Please notify our intake coordinator if you decline consent and would like an outside referral.

Consent Acknowledgment
I have read and understood the information above regarding the use of AI, video recordings, insurance requirements, and confidentiality. I understand my rights and responsibilities and have had the opportunity to ask questions.

By signing below, I voluntarily consent to:

The use of HIPAA-compliant AI in documentation
Short video recordings for training/supervision (if applicable)
Being honest about the purpose of testing and being responsible for payment if insurance denies coverage due to non-medical use
Understanding that public reviews may impact confidentiality

At BonPsy Wellness, testing is designed to be comprehensive, efficient, and tailored to your individual needs. The full process typically includes three key appointments:

Intake Appointment
This is your first meeting with a licensed clinician, either virtually or in person. During this session:

You'll share your current concerns, history, and what you're hoping to learn through testing. Sessions can be brief (15–20 minutes) if you're focused on a specific concern, or closer to 45 minutes if your needs are more complex.
This appointment helps us determine what testing battery is most appropriate for you.

Testing Appointment (In-Person)
This is the longest appointment in the process, typically lasting 4 to 6 hours. You’ll meet with one of our trained psychometrists who will guide you through a series of psychological and/or neuropsychological tests tailored to your needs.
Please plan to be at our office for the majority of the day and bring snacks, water, and any necessary accommodations.

Feedback Appointment
In this 30–45 minute session (via video or in person), your clinician will:

Walk you through your results
Explain what diagnoses (if any) were ruled in or ruled out
Share specific, actionable treatment recommendations
Your full written report will be finalized and shared via our secure patient portal approximately two weeks after the feedback session, provided that any outstanding balance has been paid.

Submitting Records
To help us understand your background and avoid duplicate testing, we ask that you upload or email any relevant documentation prior to your intake appointment, such as:

• Previous psychological or neuropsychological evaluations
  School testing (e.g., IEP, 504 plans, psychoeducational assessments)
  Medical or mental health records you believe are relevant
  Please send these documents to support@claritypsychologicaltesting.com or upload them directly to your patient portal.

Important Limitations & Patient Responsibilities
Medical Necessity and Insurance Coverage
Clarity Psychological Testing is a medically based testing practice. We do not conduct evaluations intended for legal, forensic, or administrative purposes such as:

Court-ordered assessments
Custody or adoption evaluations
Surrogacy screenings
Disability or capacity evaluations
Competency or fitness-for-duty assessments
These types of evaluations do not meet the definition of “medical necessity” as defined by insurance companies and are not covered by your plan. If we learn that you have misrepresented the purpose of your evaluation (intentionally or unintentionally), or if your case becomes part of a legal proceeding after testing, you will be held responsible for the full standard rate of services, not the discounted insurance rate. You may also incur additional fees for any required travel, correspondence, or legal consultation.

Additionally, once you’ve completed testing at our office, you may forfeit the right to later seek testing with a board-certified forensic psychologist, which could affect the outcome of legal or disability claims. Please be honest and clear about your intended use for testing at the time of intake.

Right to Decline Cases
Clarity reserves the right to decline any testing case if it is outside our scope of practice, incompatible with our scheduling, or otherwise not a good clinical fit. We aim to ensure that every client receives appropriate, ethical, and effective care.

Autism Evaluations
At this time, we do not administer the ADOS-2, a standardized diagnostic tool often required for programs or educational accommodations for Autism. However, we can screen for Autism spectrum traits as part of a broader evaluation when questions about mood, anxiety, or attention concerns are also present.

Final Report & Payment Policy
While we do not withhold medical records for non-payment, we do not continue working on cases for which there is an outstanding balance. Once your feedback session is complete, your final diagnoses need to be assigned, report polished, and treatment recommendations added. This step is not done until the patient's account is current. Therefore, if your insurance delays the claim or you have an outstanding balance, there may be a delay in getting your final report. 

Please ensure that your account is in good standing to avoid delays in the final report.

At BonPsy Wellness, your privacy and the protection of your sensitive information are our top priorities. We follow all applicable federal and state laws—including HIPAA—to ensure your confidentiality is safeguarded at every step.

How Your Information Is Used
We will never share your personal health information without your explicit written consent, unless required by law. That means:

You decide if we speak with others (e.g., schools, family, or medical providers).
If you’re using insurance, we may share limited information (such as diagnosis codes or treatment dates) with your insurance company to secure authorization or payment.

Exceptions to Confidentiality (When Disclosure Is Required by Law)
In rare but important circumstances, we are legally and ethically required to break confidentiality without your consent to ensure your safety or the safety of others:

Threat to Others: If you disclose a credible threat to harm someone, we are obligated to take protective action. This may include notifying the potential victim, alerting law enforcement, and/or arranging for hospitalization.

Threat to Yourself: If you are at risk of harming yourself and are unable to stay safe, we may seek emergency support, including hospitalization, and may reach out to family or trusted individuals to help keep you safe.

Inability to Care for Basic Needs: If your mental health condition prevents you from meeting your basic needs (such as food, shelter, or medical care), we may need to disclose limited information to initiate protective support.

These situations are extremely rare in an outpatient setting. If such a circumstance arises, we will make every reasonable effort to discuss our plan with you before taking any action—unless doing so would increase the risk of harm.

Mandated Reporting: Legal and Ethical Responsibility
All licensed clinicians in California are mandated reporters under California law (Penal Code § 11164–11174.3). This means we are legally required to report certain situations to the appropriate authorities, even without your consent. These include:

Suspected elder/child abuse or neglect
Abuse or neglect of a dependent adult or elder (age 65 or older)
Serious threats of harm to oneself or others
Mandated reporting is not optional—if a clinician has a reasonable suspicion based on what you share or what is observed, they must file a report with the appropriate child protective services or adult protective services agency, or contact law enforcement.

We understand this may feel concerning, and we encourage you to talk to your clinician if you have questions about this policy.

Professional Consultation
Occasionally, we may consult with other licensed professionals about difficult clinical situations to ensure the best care. In these cases, your identity is never disclosed, and confidentiality is strictly maintained.

Special Considerations for Minors
If you are under 18, please note that parents or legal guardians may have the legal right to access parts of your record or treatment information. However, we believe that privacy is important for building trust in therapy. We will work with both you and your parent(s) or guardian(s) to clarify:

What information can be shared
What topics should remain confidential
This helps support a safe and respectful therapeutic environment for everyone involved.

Use of Supervision and Recording

BonPsy Wellness is a teaching facility that includes the work of trained psychometrists, graduate-level interns, and pre-licensed professionals, all of whom operate under the direct supervision of licensed psychologists. To support quality assurance, clinical training, and adherence to standardized testing procedures, we may periodically monitor or record sessions—in part or in full—for supervision and educational purposes.

This may include audio or video recordings, which are reviewed only by authorized supervisory staff for the sole purpose of enhancing clinical skill, ensuring fidelity to testing protocols, and maintaining the highest standards of care.

All team members—including employees and independent contractors—have signed a Business Associate Agreement (BAA), legally binding them to maintain strict confidentiality of your Protected Health Information (PHI). They are prohibited from sharing any client information outside of our practice except as required by law (e.g., mandated reporting).

Your privacy and trust are deeply valued, and we are committed to ensuring that all training and supervision practices are handled with discretion, professionalism, and full legal compliance.

Please note that electronic communication methods—including phone calls, text messages, and email—are not fully secure, and there is a potential risk that your privacy could be compromised. While BonPsy may use these methods to communicate with you for convenience, you have the right to opt out of any or all of these channels. If you prefer not to be contacted by phone, text, or email, please let us know, and we will honor your preferences.

For all non-urgent matters, we strongly encourage you to use our secure patient portal, which offers the highest level of privacy and data protection.

Please Note:
Allow up to 24 business hours for a response to messages.
Messages received after business hours, on weekends, or on holidays will be addressed the next business day. If you or someone you know is experiencing a mental health crisis or life-threatening emergency, please call 9-1-1 or go to the nearest emergency room.

Psychological testing through health insurance is intended only for medically necessary purposes, such as clarifying a mental health diagnosis and guiding treatment planning.

By signing below, I understand that:

If I choose to omit or misrepresent information about the purpose of this evaluation,
Or if I am using insurance for non-medical reasons (such as academic accommodations, disability documentation, legal cases, or custody evaluations),
My insurance provider may later refuse to pay or request a reimbursement ("clawback"), and I will be financially responsible for the full cost of testing.
I confirm that I am seeking testing for medically necessary reasons related to my mental health, and I agree to be truthful in this form.

I have read and understand the statement above.

I understand that I am responsible for keeping track of my appointment times and dates and for contacting the practice 48 hours before my appointment if I need to cancel or change it for any reason.

I understand that although a reminder is sent, ultimately it is my responsibility to know when my appointments are scheduled. If you cancel the same day or do not attend your appointment, you will be automatically charged a $100.00 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, you will be prompted to leave a voicemail. 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 the 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 SHOW/CANCELLATION FEES ARE NON-­REFUNDABLE AND NOT BILLABLE TO INSURANCE­­­­­

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, BonPsy 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 BonPsy at the time of your visit for copays and immediately after your visit for any outstanding balance. It is your responsibility to inform BonPsy of any changes to your insurance during your evaluation process. If you do not notify us 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.

Payment Authorization & Financial Responsibility

By providing your payment information, you acknowledge and agree that a valid form of payment must be kept on file to schedule and hold all appointments. This card may be charged at any time for any outstanding balances on your account, including copays, deductibles, late cancellations, no-show fees, or unpaid services.

Please note that BonPsy Wellness is not a representative or agent of your insurance provider. If you have questions or concerns about denied claims, coverage, or reimbursement, we recommend contacting your insurance carrier directly using the number on the back of your insurance card.

We do not withhold medical records due to non-payment. However, we reserve the right to pause or discontinue services on open cases when a balance remains unpaid. We are committed to working with you to clarify any billing issues and encourage timely communication if you need assistance.

Patient Rights & Responsibilities

As a client at BonPsy Wellness, you have the right to:

Receive respectful and confidential care
Understand your diagnosis and treatment recommendations
Ask questions and participate in treatment decisions
Decline services at any time
You are responsible for:

Providing accurate and honest information
Arriving on time for scheduled appointments
Paying fees and balances in a timely manner
Communicating any changes in your needs or availability

Late Cancellation / No-Show Policy

Due to the extensive time commitment involved in psychological testing:

Missed testing day (without 48 hours notice): $250
Late cancellation (less than 48 hours notice): $100
These fees are not covered by insurance and will be billed directly to you.

By signing below, I acknowledge and accept the cancellation and no-show fees.

Payment Agreement Form

I understand that:

Insurance may not cover all services provided
I am financially responsible for all uncovered or denied charges, including but not limited to: materials fees, administrative charges, missed appointment fees, and non-clinical documentation
Payment is due before the final report is released
Accepted payment methods: credit/debit card, HSA/FSA, check, or online portal

Telehealth Consent (If Applicable)

If any portion of your intake, feedback, or therapy is conducted via telehealth:

Services may be provided via secure video conferencing platforms (e.g., Zoom, Doxy.me)
There are risks related to technology failures, unauthorized access, or interrupted privacy
In case of emergency or disconnection, we will contact you via phone as a backup
Please ensure you are in a private, quiet location during telehealth sessions.

I authorize BonPsy Wellness to contact the below -named providers to exchange relevant clinical information for care coordination.

Transparency Notice: Psychological Testing Materials Fee

At BonPsy Wellness, we are committed to being fully transparent—especially when it comes to any costs that may not be covered by insurance.

Due to the increasing expense of specialized testing materials—and the fact that most insurance companies, including yours, do not reimburse for these costs or adjust rates in line with inflation—we must implement a modest out-of-pocket fee in order to continue providing high-quality, in-network care.

In accordance with the No Surprises Act, we are notifying you in advance of a flat, non-refundable $150 materials fee. This fee supports:

Continued access to gold-standard, research-backed assessment tools
Our ability to serve patients within an affordable, in-network model
Avoiding the need to transition to an out-of-network or private-pay structure
We’ve intentionally kept this fee as low as possible—representing only a fraction of the actual cost—to balance accessibility with sustainability.

Next Steps:
To move forward with scheduling your psychological assessment:

You can pay the $150 materials fee via our secure payment link:
https://buy.stripe.com/7sY14n4Izd3J2NBcKe2wU00 or call our office to provide payment info.


Important Note:
We are unable to schedule your Psychoeducational Introductory Appointment until this payment is received.

If the transaction is declined or not submitted, you will receive one courtesy reminder. If no payment is received after that, your file will remain on hold until the balance is cleared.

Thank you for your understanding and partnership in supporting sustainable, high-quality care.

Before We Begin: A Quick Note About Who We Are

At CCPT, we want to be upfront with you about what makes our practice unique—and why that matters.

We are the only private psychological testing practice in both Massachusetts and California that is:

Independently owned by a single human—not a hospital system, private equity firm, or corporate board. Founded and led by a working mom of three, who’s been in the trenches of clinical care and parenthood for over a decade. Deeply committed to accepting as many insurance plans as possible—because we believe access to quality mental health care should never depend on your income We’re proud of these facts. But they come with a few realities we hope you'll understand:

What That Means for You

High demand: We receive over 400 evaluation requests every month.
Behind-the-scenes effort: Each case involves extensive work—scoring, analyzing data, writing detailed reports, and providing individualized feedback.
Staffing challenges: Great clinicians and psychometrists are rare. 

What You Can Count On
We promise to:

Deliver ethical, evidence-based, and affordable psychological care
Advocate for you and take your concerns seriously
Treat you as a whole person—not a number or diagnostic code

A Reality Check
If you’re seeking a white-glove, concierge-style experience—with instant availability, personal scheduling assistants, and cucumber water in the waiting room—we may not be the right fit. A fully private, out-of-network provider (charging $4,500–$8,500 out-of-pocket) might be a better match.

By choosing to work with us, you're embracing compassionate, high-quality care over perfection. You agree to extend us grace if things aren’t always seamless—and to share any frustrations directly with us (not Aunt Karen, Yelp, or Google reviews).

We're in this with you—and we’re honored to support your journey toward clarity.