Patient Appointment and Consent Form

Patient Intake Form

Complete this section with the patient's information and intake details.
Referral

Please enter information about your referral in the space below.
What services are you seeking?
Did someone refer you for testing or therapy?

Who referred you for testing or psychotherapy?
Where does the person who referred you work?

Who are you in relation to the patient?
If the patient is over the age of 18 and doesn't have a legal guardian, they must fill out this form as the patient.

Sorry we need an authorized person to fill out the form.
Please have someone with legal authority to consent to this psychological evaluation for the patient fill out this form.

Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
What is your gender identity?

Other
If you said, other please describe
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Patient's Name

First NameMiddle NameLast Name
Patient Date of Birth

MonthDayYear
Date
Patient Age
What is the patient's gender?

Other
If other was selected, please describe:
Parent / Guardian Name

First NameLast Name
Patient Address (If Multiple, put address associated with Patient's Insurance Plan)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent / Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent / Guardian Email Address
example@example.com
Who is filling out this form?

First NameLast Name

Sorry, your child is too young to do testing with us right now.
We are sorry. We do not currently accept patients under the age of 5 at this time. Please contact us around your child's fifth birthday and we will get him on the schedule.

Insurance Questions
How do you pay for the testing or therapy services?

Insurance Authorization Form
I authorize the release of information from my medical record to the insurance companies or other third-party payers named in this form. This information shall include all information necessary to submit and process claims, such as my name, date of birth, address, medical diagnosis, and services provided to me. If the practice has already shared information with the insurance company or other third-party payer at the time I revoke this authorization, it is too late to prevent that information from being shared. This authorization is necessary for the practice to determine eligibility for treatments or benefits or to pay for treatments I receive, but the practice cannot condition treatment on the provision of this authorization. This authorization shall be effective for 1 year from the date of my signature, unless I contact the practice in writing any time prior to then to revoke. If you are using Medicare benefits, you also agree to the following: I request that payment of authorized Medicare benefits be made either to me or on my behalf to the name of provider of service and (or)supplier for any services furnished to me by that provider of service and (or)supplier. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related service. In consideration of the services provided to me, I assign all benefits to the practice, if accepted, and authorize the insurance companies on this form to make payments directly to the practice and its affiliates on my behalf.Please scroll to the end to read the entire text
By signing, I certify that I have read the entire text and agree to the above terms and authorize Collin Testing and Psychological Services PLLC to bill my insurance plans for the services rendered.

Which of the following best describes your insurance?

Consent to Services Testing
A psychological evaluation is often conducted to determine what, if any, diagnoses someone has, and to use those diagnoses to provide treatment recommendations on how to best help and support the client. This document is designed to inform you about the testing processes, including what you can expect during the evaluation, the associated costs, and the potential risks and benefits involved. It also outlines important policies regarding confidentiality, billing, insurance benefits, cancellations, and your rights and responsibilities as a client. By reviewing and signing this agreement, you acknowledge your understanding and acceptance of these terms.

Your participation in a psychological evaluation or psychotherapy is voluntary and you have the right to withdraw from the evaluation process at any time. If you have any questions while reading through this form and need additional clarification, please contact us at Contact@CollinTesting.com or 828.630.9347.

Testing Process

I understand that the psychological evaluation typically involves three appointments (an interview, testing, and feedback session). The first interview appointment is always a telehealth unless otherwise stated by your clinician.

I understand that I can expect to receive my report via the patient portal within two weeks after the last evaluation appointment unless otherwise specified by the clinician, and I will contact Collin Testing and Psychological Services if I haven't received my report.

I can request corrections to my health information by contacting my clinician. A written response will be provided within 60 days of my request.
I understand that I must complete all my online questionnaires and send them to informants (if applicable) within 1-2 days of receiving the email to avoid delays in getting test results.

I understand that services related to the psychological evaluation are considered complete after the report is provided to me, but I am welcome to communicate any requested changes or corrections after receiving the initial draft of the report.

Testing Fees

I understand that I will pay a non-refundable $250 testing materials fee, which covers the costs of testing not reimbursed by insurance (e.g., testing materials, licensing fees), which will be charged to the credit or debit card on file on at the time of my testing appointment or shortly afterwards unless the client explicitly specifies an alternative financial arrangement.

I understand that I am responsible for verifying my insurance coverage before consenting to services. While Collin Testing and Psychological Services will attempt to verify insurance benefits and may provide a cost estimate, this is not a guarantee of coverage.
I understand that I am responsible for all charges if my insurance fails to reimburse Collin Testing and Psychological Services for any reason.

I understand I will pay $200 per hour for any testing time exceeding that which is reimbursed by insurance, up to $2,500 unless otherwise agreed.
I will notify Collin Testing and Psychological Services as soon as possible of any insurance changes to ensure accurate cost estimates.

I understand that if my insurance changes at any time during the testing process, the evaluation may not be covered, and I may be responsible for the full $2,500 fee. Even with in-network coverage, pre-authorization may be required, and failure to obtain it could result in denial of coverage.

I understand that some plans may not cover testing. In such cases, I am responsible for the full cost.

Cancellation Policy
I understand that last minute cancellations result in significant lost income for the clinician, the practice, and prevent someone else on the wait list from getting their testing sooner.

I understand that rescheduling with advance notice shows respect for the clinician's time and allows Collin Testing to schedule someone else in my place. 
I understand that I can avoid late cancellation and no-show fees by notifying Collin Testing when I cannot make an appointment as soon as possible.
I understand that if I no show or cancel my appointment within 72 hours of the appointment, a no show or late cancellation fee of $200 for clinical interviews, standalone feedback sessions, and therapy, and a $350 cancellation fee for testing appointments will be charged to my credit or debit card on file.

I understand that I can talk to my clinician about emergencies or circumstances which may result in waiving this fee.

If the card on file is declined, rescheduling my appointment requires full payment of any outstanding cancellation or no-show fees before rescheduling will occur and requires a valid credit or debit card on file.

I understand requests such as letters to employers incur a $200 fee.

Court Appearances

In the event that the clinician's appearance is required in connection with a court case (whether civil or criminal), the clinician requires 30 days advance notice for providing deposition or trial testimony. This notice allows for the clinician to arrange their schedule and adequately prepare for testimony. By signing this document, I agree to provide 30 days advance notice. I further agree that any shorter notice would fail to allow a reasonable time for compliance and subject the clinician to undue burden and (potentially) expense.
In the event that I or my counsel requires the clinician's testimony without providing advance notice as described above, I further agree to reimburse any attorney fees Collin Testing incurs in association with objecting to the untimely subpoena.

Third-party informants

A collateral informant for a psychological evaluation is someone who provides information for a psychological evaluation. This could be a family member, friend, teacher, therapist, and/or other professional who knows the person being evaluated (the client). Collateral informants can be extremely helpful to the evaluation process, and you will likely be given a hyperlink to send to these third-party informants to complete an online questionnaire to inform the evaluation process.

I understand that including any third-party informants in the evaluation is voluntary, and I am not obligated to include any third parties in the evaluation process.

I understand that I can withdraw consent from a third-party informant at any time during the evaluation process by communicating with the clinician both orally and in writing. If the request is made before the clinician has had time to read the responses, then the clinician will delete this informant’s information and not consider it in the psychological evaluation process.

I understand that I have can request revisions and/or corrections, including the removal of information provided by third-party informants. While an updated report may be provided within 60 days of the request, diagnoses and treatment recommendations may not be changed. I acknowledge that previously-released copies of the report cannot be retrieved or altered.

I understand that after I receive my psychological evaluation report, I can request corrections/revisions revisions, including the removal of information provided by third-party informants during the evaluation process.

I understand that if I request removal of information provided by any third-party informant, an updated copy may be provided within 60 days of the request. However, I also acknowledge that diagnoses and treatment recommendations influenced by that third-party informant’s disclosures may not be changed.
I also understand that Collin Testing and Psychological Services may have already sent copies of the report, as consented by me or my legally responsible person prior to this request, that include the third-party information, and those previously released copies cannot be retrieved or altered. Therefore, I understand that while the information can be removed from future reports, it may still exist in previously released versions.

I understand that forwarding a questionnaire link provided by Collin Testing and Psychological Services to a third party, via any means, constitutes my consent for that individual to participate as a collateral informant in the psychological evaluation even if I do not sign a written release of information form provided on the patient portal.

I understand that if I decide to include a third-party informant in the evaluation process that the information that the third party discloses will be included in the psychological evaluation and evaluation record.

I understand that Collin Testing and Psychological Services provides a disclosure outlining the role of a third-party informant prior to them providing information. While not required, I can provide context to help all third-party informants understand their role in the evaluation.

General Confidentiality Disclosures

I understand that completing online questionnaires thoroughly enhances the evaluation's accuracy. I understand that my decision to provide information via online questionnaires is voluntary and I can decide to stop at any time.

I understand that technical issues may affect data collection. I recognize that completing questionnaires in one sitting is recommended to avoid data loss.

I understand that telehealth sessions may be discontinued if a higher level of care is needed or if I am in a different state than my clinician.
I understand that information disclosed during therapy or testing that indicates potential harm to myself or others may be disclosed without my consent.

Disclosures and Written Records

Information disclosed during sessions and any related written records are confidential and cannot be disclosed without written authorization, except as is otherwise permitted or required by law.
A notice of privacy practices has been provided which further explains HIPAA Rights and state laws concerning disclosure.

Consent to Disclosures for Continuity of Care

By signing this document, I authorize Collin Testing and Psychological Services to forward my psychological evaluation report to the medical or mental health providers and allied health professionals who made a written referral requesting the psychological evaluation to establish continuity of care. I understand that I can revoke this authorization at any time by notifying Collin Testing and Psychological Services that I do not wish to have my report forwarded to the referring provider. I understand that this authorization will be effective for one calendar year from the date this consent to services document is signed. I understand that by signing this document, the person or entity receiving this information may not be required to protect it in the same way under federal privacy law.

Appointing a Representative

If you have a designated person with medical power of attorney or a legal guardian, they can exercise your rights and make decisions about your health information. We will verify their authority before taking any action.

Acknowledgement of Client’s Rights & Responsibilities

I understand that I can withdraw consent for evaluation or therapy services without affecting future care or benefits.
I understand that I will be asked to provide emergency contacts and understand they may be used if necessary.

I understand that I can go to the nearest emergency room in the case of a crisis.

I understand that the use or possession of drugs, alcohol, firearms, and weapons is prohibited at the offices of Collin Testing and Psychological Services.
In a medical emergency, I authorize Collin Testing and Psychological Services staff to seek emergency services.

After reading this evaluation, I agree to all the terms outlined in this document. I consent to psychological evaluation and treatment services and understand I may stop or refuse treatment at any time.

Disability Rights Contact Information: Phone: 919-856-2195 / Toll-Free: 877-235-4210 / TTY: 888-268-5525 / Fax: 919-856-2244 / Email: info@disabilityrightsnc.org / Address: 3724 National Drive, Ste 100, Raleigh, NC 27612 / www.disabilityrightsnc.org

Consent to Clinician Use of Artificial Intelligence (AI)

As part of their ongoing commitment to provide the best possible service, your provider has opted to use HIPAA compliant artificial intelligence (AI) assists in generating clinical documentation, report writing, and other tasks. This allows for more time and focus to be spent on interactions with you and/or the client, additional tests, and clinicians time to provide more accurate and well described diagnostic conclusions and treatment recommendations. Your clinician always reviews all of the content produced by AI for accuracy and completeness. The recording and transcript of conversations are kept confidential using HIPAA compliant sources. Collin Testing uses AI in a way that prioritizes the privacy and confidentiality of your personal health information, while providing you with better quality reports treatment notes, and/or therapy. Your session information is strictly used for the purpose of the psychological evaluation or treatment. Your information is subject to strict data privacy regulations and is always secured and encrypted. Stringent business associate agreements ensure data privacy and HIPAA compliance. By signing this form, you consent to the use of artificial intelligence as described. You acknowledge that your participation is voluntary and not a condition of receiving services from your clinician, and that you can withdraw your consent at any time.Please scroll to the end to read the entire text
Consent to Services Therapy
Informed Consent for Psychological Services
Introduction I understand that this document is designed to inform me about the psychotherapy and evaluation processes, potential risks and benefits, and important policies regarding confidentiality, billing, insurance benefits, cancellations, and my rights and responsibilities as a client. By reviewing and signing this agreement, I acknowledge my understanding and acceptance of these terms.
My participation in a psychological evaluation or psychotherapy is voluntary, and I have the right to withdraw from the evaluation or treatment process at any time. If I have any questions while reading through this form and need additional clarification, I can contact the practice at Contact@CollinTesting.com or 828.630.9347.
Psychotherapy Cost
• I understand that psychotherapy includes an initial clinical interview scheduled by the practice, and follow-up appointments are scheduled directly with the clinician.
• I understand that while the practice may provide an estimate of costs, it is ultimately my responsibility to contact my insurance company to verify my coverage, deductibles, and out-of-pocket costs.
• I will notify the practice as soon as possible of any insurance changes to ensure accurate cost estimates.
• I understand that some plans may not cover psychotherapy, and in these cases, I am responsible for all costs at the self-pay rate of $200 per hour.
Cancellation Policy
• I understand that last-minute cancellations result in significant lost income for the clinician and the practice.
• I understand that rescheduling with advance notice shows respect for the clinician's time and allows the practice to schedule someone else in my place.
• I understand that I can avoid late cancellation and no-show fees by notifying my clinician as soon as possible when I cannot make an appointment.
• I understand that I can talk to my clinician about emergencies or circumstances which may result in waiving a cancellation fee.
• Non-Medicaid Clients: If I do not have Medicaid coverage, I must keep a valid credit or debit card on file. I understand that cancellations made with less than 24 hours' notice, or no-shows, will incur a $200 fee charged to this card. If my card is declined, I must pay all outstanding fees before rescheduling.
Court Appearances In the event that the clinician's appearance is required in connection with a court case (whether civil or criminal), I understand that the clinician requires 30 days advance notice for providing deposition or trial testimony. This notice allows the clinician to arrange their schedule and adequately prepare. I agree to provide 30 days advance notice and understand that shorter notice would fail to allow reasonable time for compliance and subject the clinician to undue burden and expense.
• I agree to pay the clinician's hourly rate of [Insert Hourly Rate Here] for all time associated with legal proceedings, including preparation, travel, and testimony, as these fees are generally not covered by insurance.
• If I or my counsel requires the clinician's testimony without providing advance notice as described above, I agree to reimburse any attorney fees the practice incurs in association with objecting to the untimely subpoena.
General Confidentiality & Written Records Information disclosed during sessions, testing, and any related written records are confidential and cannot be disclosed without my written authorization, except as otherwise permitted or required by law. I acknowledge that a notice of privacy practices has been provided to me which further explains my HIPAA rights and state laws concerning disclosure.
I understand that confidentiality may be broken without my consent in certain legal or emergency situations, including:
• Information indicating potential harm to myself or others.
• Suspected child abuse or neglect.
• Suspected elder or dependent adult abuse.
• A direct court order signed by a judge.
• I understand that telehealth sessions may be discontinued if a higher level of care is needed or if I am located in a different state than my clinician.
Communication Policy I understand that standard email and SMS text messaging are not entirely secure forms of communication. I agree to avoid sharing sensitive medical or personal health information through these channels to protect my privacy.
Appointing a Representative I understand that if I have a designated person with medical power of attorney or a legal guardian, they can exercise my rights and make decisions about my health information. The practice will verify their authority before taking any action.
Acknowledgement of Client’s Rights & Responsibilities
• I understand that I can withdraw consent for evaluation or therapy services without affecting future care or benefits.
• I understand that I will be asked to provide emergency contacts and understand they may be contacted if necessary.
• I understand that I can go to the nearest emergency room in the case of a crisis.
• I understand that the use or possession of drugs, alcohol, firearms, and weapons is prohibited at the offices of the practice.
• In a medical emergency, I authorize the practice staff to seek emergency services.
Consent to Clinician Use of Artificial Intelligence (AI) As part of their ongoing commitment to provide the best possible service, my provider has opted to use HIPAA-compliant artificial intelligence (AI) to assist in generating clinical documentation, report writing, and other tasks. This allows for more time and focus to be spent on interactions with me, additional testing, and providing accurate, well-described diagnostic conclusions and treatment recommendations.
• I understand my clinician always reviews all of the content produced by AI for accuracy and completeness.
• The recording and transcript of conversations are kept confidential using HIPAA-compliant sources.
• The practice uses AI in a way that prioritizes the privacy and confidentiality of my personal health information.
• My session information is strictly used for the purpose of my psychological evaluation or treatment. It is subject to strict data privacy regulations and is always secured and encrypted through stringent Business Associate Agreements (BAAs).
Please scroll to the end to read the entire text
By signing below, I certify that I have read the entire consent to services text and agree to the terms and conditions associated with the Consent to Services Agreement.
A valid credit or debit card is required to book your appointment. What is the credit or debit card type?
Please enter credit card type (e.g., Visa, Amex, Mastercard)
What are the last four digits of the credit or debit card?
Credit or Debit Card Authorization Agreement
By signing below, I authorize Collin Testing and Psychological Services, PLLC to charge the entered credit or debit card for services rendered (also referred to as the "card on file"), as outlined in the disclosure statement and policies I and/or the client have signed. I understand that a valid credit or debit card must be on file in order to schedule an appointment.

This authorization includes charging the card on file for any outstanding balances without further consent on the day the service was provided, including:

Fees for services: This includes the cost of all services provided, as well as any additional fees outlined in the consent document.

FOR TESTING PATIENTS ONLY: Includes any agreed-upon testing and materials fees (e.g., $250). This specific fee does not apply to therapy patients.

Insurance denials: If insurance denies the claims or refuses to pay for any reason, the card on file will be charged for the remaining balance.

No-show and late cancellation fees: $200 for missed intake or therapy sessions, and $350 for missed testing and feedback sessions. I understand that I must communicate with my clinician to waive this fee.

Additional Financial Policies:

No Cash: I understand that cash is not accepted.

Collections: I understand that any remaining balance after attempts to collect payment may be referred to a collections agency, and I will be responsible for communicating with and paying the agency directly.

HSA and FSA Cards: HSA and FSA cards can only be used for services deemed medically necessary by the IRS, as outlined in IRS Publication 502. Collin Testing and Psychological Services is not responsible for any taxes or penalties imposed by the IRS should a service paid for with an HSA/FSA card be deemed medically unnecessary in an audit.

Cardholder Certification:
I authorize Collin Testing and Psychological Services, PLLC to charge the credit card indicated on this form for the services and fees outlined above. I certify that I am an authorized user of the card on file and will not dispute these scheduled transactions with my bank, provided the transactions correspond to the terms indicated in this agreement.
 
Fees for services: This includes the cost of all services provided.

Insurance denials: If insurance denies the claims or refuses to pay for any reason, the card on file will be charged for the remaining balance.

No Cash: I understand that cash is not accepted.
No-show and late cancellation fees: $200 for missed intake or therapy sessions, and $350 for missed testing and feedback sessions. I understand that I must communicate with my clinician to waive this fee. 

I understand that any remaining balance after attempts to collect payment may be referred to a collections agency, and I will be responsible for communicating with and paying the agency directly.

HSA and FSA cards can only be used for services deemed medically necessary by the IRS, as outlined in IRS Publication 502. Collin Testing and Psychological Services is not responsible for any taxes or penalties imposed by the IRS should a service paid for with an HSA/FSA card be deemed medically unnecessary in an audit.

I understand that a valid credit or debit card must be on file and will need to be on file in order to schedule your appointment.

I authorize Collin Testing and Psychological Services, PLLC to charge the credit and/or debit card on file for the services provided, test and materials fees ($250) and any no show or late cancellation fees without further consent.

I authorize Collin Testing and Psychological Services to charge the credit card indicated on this form for services rendered, including any agreed-upon late cancellation or no-show fees. I certify that I am an authorized user of the above card and will not dispute these scheduled transactions with my bank, provided the transactions correspond to the terms indicated in this agreement.Please scroll to the end to read the entire text
I authorize Collin Testing and Psychological Services, PLLC to charge the credit card indicated on this form for the services and fees outlined above. I certify that I am an authorized user of the card on file and will not dispute these scheduled transactions with my bank, provided the transactions correspond to the terms indicated in this agreement.

You either chose to do self-pay OR we do not accept your insurance plan. Would you like to proceed by paying out-of-pocket? (Standard rates apply: $200/therapy session or $2,400/evaluation)

If the cost is too high, we offer a limited number of sliding scale slots based on financial need. Would you like to be considered for a reduced rate?

What is your estimated household income?

Your sliding scale rate is $2,000 for a psychological evaluation and $165 per therapy session. Would you like to proceed?

Your sliding scale rate is $1,600 for a psychological evaluation and $135 per therapy session. Would you like to proceed?

Your sliding scale rate is $1,200 for a psychological evaluation and $100 per therapy session. Would you like to proceed?

We are sorry.
We apologize that we were unable to help you.

Agreement to Self-pay
I understand that Collin Testing and Psychological Services may be in-network with my insurance, which may cover some or all of the services provided. I choose not to have claims submitted to my insurance and will pay for services at the self-pay rate identified in this form. Payments I make will not count towards my insurance deductible. I will not file insurance claims for these services, and neither will Collin Testing and Psychological Services. I am solely responsible for paying the agreed fees at the time of service and will not request refunds, adjustments, or retroactive billing. By signing below, I have read and understood this self-pay agreement, had my questions answered, and have chosen this option after considering payment alternatives.Please scroll to the end to read the entire text
By signing below, I certify that I have read the entire agreement to self-pay, and I agree to the terms and conditions outlined in the text, decline to use my insurance, and elect to self-pay at the agreed upon rates in this document.
Consent to Services Testing
A psychological evaluation is often conducted to determine what, if any, diagnoses someone has, and to use those diagnoses to provide treatment recommendations on how to best help and support the client. This document is designed to inform you about the testing processes, including what you can expect during the evaluation, the associated costs, and the potential risks and benefits involved. It also outlines important policies regarding confidentiality, billing, insurance benefits, cancellations, and your rights and responsibilities as a client. By reviewing and signing this agreement, you acknowledge your understanding and acceptance of these terms.

Your participation in a psychological evaluation or psychotherapy is voluntary and you have the right to withdraw from the evaluation process at any time. If you have any questions while reading through this form and need additional clarification, please contact us at Contact@CollinTesting.com or 828.630.9347.

Testing Process

I understand that the psychological evaluation typically involves three appointments (an interview, testing, and feedback session). The first interview appointment is always a telehealth unless otherwise stated by your clinician.

I understand that I can expect to receive my report via the patient portal within two weeks after the last evaluation appointment unless otherwise specified by the clinician, and I will contact Collin Testing and Psychological Services if I haven't received my report.

I can request corrections to my health information by contacting my clinician. A written response will be provided within 60 days of my request.
I understand that I must complete all my online questionnaires and send them to informants (if applicable) within 1-2 days of receiving the email to avoid delays in getting test results.

I understand that services related to the psychological evaluation are considered complete after the report is provided to me, but I am welcome to communicate any requested changes or corrections after receiving the initial draft of the report.

Testing Fees

I understand that I will pay a non-refundable $250 testing materials fee, which covers the costs of testing not reimbursed by insurance (e.g., testing materials, licensing fees), which will be charged to the credit or debit card on file on at the time of my testing appointment or shortly afterwards unless the client explicitly specifies an alternative financial arrangement.

I understand that I am responsible for verifying my insurance coverage before consenting to services. While Collin Testing and Psychological Services will attempt to verify insurance benefits and may provide a cost estimate, this is not a guarantee of coverage.
I understand that I am responsible for all charges if my insurance fails to reimburse Collin Testing and Psychological Services for any reason.

I understand I will pay $200 per hour for any testing time exceeding that which is reimbursed by insurance, up to $2,500 unless otherwise agreed.
I will notify Collin Testing and Psychological Services as soon as possible of any insurance changes to ensure accurate cost estimates.

I understand that if my insurance changes at any time during the testing process, the evaluation may not be covered, and I may be responsible for the full $2,500 fee. Even with in-network coverage, pre-authorization may be required, and failure to obtain it could result in denial of coverage.

I understand that some plans may not cover testing. In such cases, I am responsible for the full cost.

Cancellation Policy
I understand that last minute cancellations result in significant lost income for the clinician, the practice, and prevent someone else on the wait list from getting their testing sooner.

I understand that rescheduling with advance notice shows respect for the clinician's time and allows Collin Testing to schedule someone else in my place. 
I understand that I can avoid late cancellation and no-show fees by notifying Collin Testing when I cannot make an appointment as soon as possible.
I understand that if I no show or cancel my appointment within 72 hours of the appointment, a no show or late cancellation fee of $200 for clinical interviews, standalone feedback sessions, and therapy, and a $350 cancellation fee for testing appointments will be charged to my credit or debit card on file.

I understand that I can talk to my clinician about emergencies or circumstances which may result in waiving this fee.

If the card on file is declined, rescheduling my appointment requires full payment of any outstanding cancellation or no-show fees before rescheduling will occur and requires a valid credit or debit card on file.

I understand requests such as letters to employers incur a $200 fee.

Court Appearances

In the event that the clinician's appearance is required in connection with a court case (whether civil or criminal), the clinician requires 30 days advance notice for providing deposition or trial testimony. This notice allows for the clinician to arrange their schedule and adequately prepare for testimony. By signing this document, I agree to provide 30 days advance notice. I further agree that any shorter notice would fail to allow a reasonable time for compliance and subject the clinician to undue burden and (potentially) expense.
In the event that I or my counsel requires the clinician's testimony without providing advance notice as described above, I further agree to reimburse any attorney fees Collin Testing incurs in association with objecting to the untimely subpoena.

Third-party informants

A collateral informant for a psychological evaluation is someone who provides information for a psychological evaluation. This could be a family member, friend, teacher, therapist, and/or other professional who knows the person being evaluated (the client). Collateral informants can be extremely helpful to the evaluation process, and you will likely be given a hyperlink to send to these third-party informants to complete an online questionnaire to inform the evaluation process.

I understand that including any third-party informants in the evaluation is voluntary, and I am not obligated to include any third parties in the evaluation process.

I understand that I can withdraw consent from a third-party informant at any time during the evaluation process by communicating with the clinician both orally and in writing. If the request is made before the clinician has had time to read the responses, then the clinician will delete this informant’s information and not consider it in the psychological evaluation process.

I understand that I have can request revisions and/or corrections, including the removal of information provided by third-party informants. While an updated report may be provided within 60 days of the request, diagnoses and treatment recommendations may not be changed. I acknowledge that previously-released copies of the report cannot be retrieved or altered.

I understand that after I receive my psychological evaluation report, I can request corrections/revisions revisions, including the removal of information provided by third-party informants during the evaluation process.

I understand that if I request removal of information provided by any third-party informant, an updated copy may be provided within 60 days of the request. However, I also acknowledge that diagnoses and treatment recommendations influenced by that third-party informant’s disclosures may not be changed.
I also understand that Collin Testing and Psychological Services may have already sent copies of the report, as consented by me or my legally responsible person prior to this request, that include the third-party information, and those previously released copies cannot be retrieved or altered. Therefore, I understand that while the information can be removed from future reports, it may still exist in previously released versions.

I understand that forwarding a questionnaire link provided by Collin Testing and Psychological Services to a third party, via any means, constitutes my consent for that individual to participate as a collateral informant in the psychological evaluation even if I do not sign a written release of information form provided on the patient portal.

I understand that if I decide to include a third-party informant in the evaluation process that the information that the third party discloses will be included in the psychological evaluation and evaluation record.

I understand that Collin Testing and Psychological Services provides a disclosure outlining the role of a third-party informant prior to them providing information. While not required, I can provide context to help all third-party informants understand their role in the evaluation.

General Confidentiality Disclosures

I understand that completing online questionnaires thoroughly enhances the evaluation's accuracy. I understand that my decision to provide information via online questionnaires is voluntary and I can decide to stop at any time.

I understand that technical issues may affect data collection. I recognize that completing questionnaires in one sitting is recommended to avoid data loss.

I understand that telehealth sessions may be discontinued if a higher level of care is needed or if I am in a different state than my clinician.
I understand that information disclosed during therapy or testing that indicates potential harm to myself or others may be disclosed without my consent.

Disclosures and Written Records

Information disclosed during sessions and any related written records are confidential and cannot be disclosed without written authorization, except as is otherwise permitted or required by law.
A notice of privacy practices has been provided which further explains HIPAA Rights and state laws concerning disclosure.

Consent to Disclosures for Continuity of Care

By signing this document, I authorize Collin Testing and Psychological Services to forward my psychological evaluation report to the medical or mental health providers and allied health professionals who made a written referral requesting the psychological evaluation to establish continuity of care. I understand that I can revoke this authorization at any time by notifying Collin Testing and Psychological Services that I do not wish to have my report forwarded to the referring provider. I understand that this authorization will be effective for one calendar year from the date this consent to services document is signed. I understand that by signing this document, the person or entity receiving this information may not be required to protect it in the same way under federal privacy law.

Appointing a Representative

If you have a designated person with medical power of attorney or a legal guardian, they can exercise your rights and make decisions about your health information. We will verify their authority before taking any action.

Acknowledgement of Client’s Rights & Responsibilities

I understand that I can withdraw consent for evaluation or therapy services without affecting future care or benefits.
I understand that I will be asked to provide emergency contacts and understand they may be used if necessary.

I understand that I can go to the nearest emergency room in the case of a crisis.

I understand that the use or possession of drugs, alcohol, firearms, and weapons is prohibited at the offices of Collin Testing and Psychological Services.
In a medical emergency, I authorize Collin Testing and Psychological Services staff to seek emergency services.

After reading this evaluation, I agree to all the terms outlined in this document. I consent to psychological evaluation and treatment services and understand I may stop or refuse treatment at any time.

Disability Rights Contact Information: Phone: 919-856-2195 / Toll-Free: 877-235-4210 / TTY: 888-268-5525 / Fax: 919-856-2244 / Email: info@disabilityrightsnc.org / Address: 3724 National Drive, Ste 100, Raleigh, NC 27612 / www.disabilityrightsnc.org

Consent to Clinician Use of Artificial Intelligence (AI)

As part of their ongoing commitment to provide the best possible service, your provider has opted to use HIPAA compliant artificial intelligence (AI) assists in generating clinical documentation, report writing, and other tasks. This allows for more time and focus to be spent on interactions with you and/or the client, additional tests, and clinicians time to provide more accurate and well described diagnostic conclusions and treatment recommendations. Your clinician always reviews all of the content produced by AI for accuracy and completeness. The recording and transcript of conversations are kept confidential using HIPAA compliant sources. Collin Testing uses AI in a way that prioritizes the privacy and confidentiality of your personal health information, while providing you with better quality reports treatment notes, and/or therapy. Your session information is strictly used for the purpose of the psychological evaluation or treatment. Your information is subject to strict data privacy regulations and is always secured and encrypted. Stringent business associate agreements ensure data privacy and HIPAA compliance. By signing this form, you consent to the use of artificial intelligence as described. You acknowledge that your participation is voluntary and not a condition of receiving services from your clinician, and that you can withdraw your consent at any time.Please scroll to the end to read the entire text
Consent to Services Therapy
Informed Consent for Psychological Services
Introduction I understand that this document is designed to inform me about the psychotherapy and evaluation processes, potential risks and benefits, and important policies regarding confidentiality, billing, insurance benefits, cancellations, and my rights and responsibilities as a client. By reviewing and signing this agreement, I acknowledge my understanding and acceptance of these terms.
My participation in a psychological evaluation or psychotherapy is voluntary, and I have the right to withdraw from the evaluation or treatment process at any time. If I have any questions while reading through this form and need additional clarification, I can contact the practice at Contact@CollinTesting.com or 828.630.9347.
Psychotherapy Cost
• I understand that psychotherapy includes an initial clinical interview scheduled by the practice, and follow-up appointments are scheduled directly with the clinician.
• I understand that while the practice may provide an estimate of costs, it is ultimately my responsibility to contact my insurance company to verify my coverage, deductibles, and out-of-pocket costs.
• I will notify the practice as soon as possible of any insurance changes to ensure accurate cost estimates.
• I understand that some plans may not cover psychotherapy, and in these cases, I am responsible for all costs at the self-pay rate of $200 per hour.
Cancellation Policy
• I understand that last-minute cancellations result in significant lost income for the clinician and the practice.
• I understand that rescheduling with advance notice shows respect for the clinician's time and allows the practice to schedule someone else in my place.
• I understand that I can avoid late cancellation and no-show fees by notifying my clinician as soon as possible when I cannot make an appointment.
• I understand that I can talk to my clinician about emergencies or circumstances which may result in waiving a cancellation fee.
• Non-Medicaid Clients: If I do not have Medicaid coverage, I must keep a valid credit or debit card on file. I understand that cancellations made with less than 24 hours' notice, or no-shows, will incur a $200 fee charged to this card. If my card is declined, I must pay all outstanding fees before rescheduling.
Court Appearances In the event that the clinician's appearance is required in connection with a court case (whether civil or criminal), I understand that the clinician requires 30 days advance notice for providing deposition or trial testimony. This notice allows the clinician to arrange their schedule and adequately prepare. I agree to provide 30 days advance notice and understand that shorter notice would fail to allow reasonable time for compliance and subject the clinician to undue burden and expense.
• I agree to pay the clinician's hourly rate of [Insert Hourly Rate Here] for all time associated with legal proceedings, including preparation, travel, and testimony, as these fees are generally not covered by insurance.
• If I or my counsel requires the clinician's testimony without providing advance notice as described above, I agree to reimburse any attorney fees the practice incurs in association with objecting to the untimely subpoena.
General Confidentiality & Written Records Information disclosed during sessions, testing, and any related written records are confidential and cannot be disclosed without my written authorization, except as otherwise permitted or required by law. I acknowledge that a notice of privacy practices has been provided to me which further explains my HIPAA rights and state laws concerning disclosure.
I understand that confidentiality may be broken without my consent in certain legal or emergency situations, including:
• Information indicating potential harm to myself or others.
• Suspected child abuse or neglect.
• Suspected elder or dependent adult abuse.
• A direct court order signed by a judge.
• I understand that telehealth sessions may be discontinued if a higher level of care is needed or if I am located in a different state than my clinician.
Communication Policy I understand that standard email and SMS text messaging are not entirely secure forms of communication. I agree to avoid sharing sensitive medical or personal health information through these channels to protect my privacy.
Appointing a Representative I understand that if I have a designated person with medical power of attorney or a legal guardian, they can exercise my rights and make decisions about my health information. The practice will verify their authority before taking any action.
Acknowledgement of Client’s Rights & Responsibilities
• I understand that I can withdraw consent for evaluation or therapy services without affecting future care or benefits.
• I understand that I will be asked to provide emergency contacts and understand they may be contacted if necessary.
• I understand that I can go to the nearest emergency room in the case of a crisis.
• I understand that the use or possession of drugs, alcohol, firearms, and weapons is prohibited at the offices of the practice.
• In a medical emergency, I authorize the practice staff to seek emergency services.
Consent to Clinician Use of Artificial Intelligence (AI) As part of their ongoing commitment to provide the best possible service, my provider has opted to use HIPAA-compliant artificial intelligence (AI) to assist in generating clinical documentation, report writing, and other tasks. This allows for more time and focus to be spent on interactions with me, additional testing, and providing accurate, well-described diagnostic conclusions and treatment recommendations.
• I understand my clinician always reviews all of the content produced by AI for accuracy and completeness.
• The recording and transcript of conversations are kept confidential using HIPAA-compliant sources.
• The practice uses AI in a way that prioritizes the privacy and confidentiality of my personal health information.
• My session information is strictly used for the purpose of my psychological evaluation or treatment. It is subject to strict data privacy regulations and is always secured and encrypted through stringent Business Associate Agreements (BAAs).
Please scroll to the end to read the entire text
By signing below, I certify that I have read the entire consent to services document and agree to the terms and conditions outlined in the text.
A valid credit or debit card is required to book your appointment. What is the credit or debit card type?
Please enter credit card type (e.g., Visa, Amex, Mastercard)
What are the last four digits of the credit or debit card?
Credit or Debit Card Authorization Agreement
By signing below, I authorize Collin Testing and Psychological Services, PLLC to charge the entered credit or debit card for services rendered (also referred to as the "card on file"), as outlined in the disclosure statement and policies I and/or the client have signed. I understand that a valid credit or debit card must be on file in order to schedule an appointment.

This authorization includes charging the card on file for any outstanding balances without further consent on the day the service was provided, including:

Fees for services: This includes the cost of all services provided, as well as any additional fees outlined in the consent document.

FOR TESTING PATIENTS ONLY: Includes any agreed-upon testing and materials fees (e.g., $250). This specific fee does not apply to therapy patients.

Insurance denials: If insurance denies the claims or refuses to pay for any reason, the card on file will be charged for the remaining balance.

No-show and late cancellation fees: $200 for missed intake or therapy sessions, and $350 for missed testing and feedback sessions. I understand that I must communicate with my clinician to waive this fee.

Additional Financial Policies:

No Cash: I understand that cash is not accepted.

Collections: I understand that any remaining balance after attempts to collect payment may be referred to a collections agency, and I will be responsible for communicating with and paying the agency directly.

HSA and FSA Cards: HSA and FSA cards can only be used for services deemed medically necessary by the IRS, as outlined in IRS Publication 502. Collin Testing and Psychological Services is not responsible for any taxes or penalties imposed by the IRS should a service paid for with an HSA/FSA card be deemed medically unnecessary in an audit.

Cardholder Certification:
I authorize Collin Testing and Psychological Services, PLLC to charge the credit card indicated on this form for the services and fees outlined above. I certify that I am an authorized user of the card on file and will not dispute these scheduled transactions with my bank, provided the transactions correspond to the terms indicated in this agreement.
 
Fees for services: This includes the cost of all services provided.

Insurance denials: If insurance denies the claims or refuses to pay for any reason, the card on file will be charged for the remaining balance.

No Cash: I understand that cash is not accepted.
No-show and late cancellation fees: $200 for missed intake or therapy sessions, and $350 for missed testing and feedback sessions. I understand that I must communicate with my clinician to waive this fee. 

I understand that any remaining balance after attempts to collect payment may be referred to a collections agency, and I will be responsible for communicating with and paying the agency directly.

HSA and FSA cards can only be used for services deemed medically necessary by the IRS, as outlined in IRS Publication 502. Collin Testing and Psychological Services is not responsible for any taxes or penalties imposed by the IRS should a service paid for with an HSA/FSA card be deemed medically unnecessary in an audit.

I understand that a valid credit or debit card must be on file and will need to be on file in order to schedule your appointment.

I authorize Collin Testing and Psychological Services, PLLC to charge the credit and/or debit card on file for the services provided, test and materials fees ($250) and any no show or late cancellation fees without further consent.

I authorize Collin Testing and Psychological Services to charge the credit card indicated on this form for services rendered, including any agreed-upon late cancellation or no-show fees. I certify that I am an authorized user of the above card and will not dispute these scheduled transactions with my bank, provided the transactions correspond to the terms indicated in this agreement.
I authorize Collin Testing and Psychological Services, PLLC to charge the credit card indicated on this form for the services and fees outlined above. I certify that I am an authorized user of the card on file and will not dispute these scheduled transactions with my bank, provided the transactions correspond to the terms indicated in this agreement.

What Medicaid insurance company do you have?

Other
If you selected other, what is the name of the payer?
Please upload a picture of the Front of your Medicaid Card. To prevent having to resubmit the form again, please upload a legible picture of your insurance card.

This card should be HealthyBlue, Amerihealth Caritas, Vaya Health, or Carolina Complete Health. If your card will not upload, please take a screen shot of the photo and upload the screen shot.
Cancelof
Please upload a picture of the BACK of your Medicaid Card. To prevent having to resubmit the form again, please upload a legible picture of your insurance card.

This card should be HealthyBlue, Amerihealth Caritas, Vaya Health, or Carolina Complete Health. If your card will not upload, please take a screen shot of the photo and upload the screen shot.
Cancelof
Please enter the member ID#
Please re-enter the member ID# to make sure its correct
Consent to Services Testing
A psychological evaluation is often conducted to determine what, if any, diagnoses someone has, and to use those diagnoses to provide treatment recommendations on how to best help and support the client. This document is designed to inform you about the testing processes, including what you can expect during the evaluation, the associated costs, and the potential risks and benefits involved. It also outlines important policies regarding confidentiality, billing, insurance benefits, cancellations, and your rights and responsibilities as a client. By reviewing and signing this agreement, you acknowledge your understanding and acceptance of these terms.

Your participation in a psychological evaluation is voluntary and you have the right to withdraw from the evaluation process at any time. If you have any questions while reading through this form and need additional clarification, please contact us at Contact@CollinTesting.com or 828.630.9347.

Testing Process

I understand that the psychological evaluation typically involves three appointments (an interview, testing, and feedback session). The first interview appointment is always a telehealth unless otherwise stated by your clinician.

I understand that I can expect to receive my report via the patient portal within two weeks after the last evaluation appointment unless otherwise specified by the clinician, and I will contact Collin Testing and Psychological Services if I haven't received my report.

I can request corrections to my health information by contacting my clinician. A written response will be provided within 60 days of my request.

I understand that I must complete all my online questionnaires and send them to informants (if applicable) within 1-2 days of receiving the email to avoid delays in getting test results.

I understand that services related to the psychological evaluation are considered complete after the report is provided to me, but I am welcome to communicate any requested changes or corrections after receiving the initial draft of the report.

Cancellation Policy for Patients With Active Medicaid Coverage

I understand that I will not be rescheduled for a follow-up appointment if I no-show or cancel my interview appointment within 72 hours of the appointment.

Coverage for Patients With Active Medicaid Coverage at the Time of Service

I understand that if I or the patient have active Medicaid coverage at the time of service that I will not be billed for any services that are covered by Medicaid aside from legitimate copays. I will only be responsible for payment if a service is not covered by Medicaid, and only if I am informed in advance and agree in writing to pay for that non-covered service.

I understand that if I or the patient have active Medicaid coverage at the date of service that I will not be charged any fees for no-shows or late cancellations.

A late cancellation (less than 72 hours) will be documented as the single exception allowed in the evaluation series. Subsequent incidents will result in the formal termination of the evaluation. Your therapist or testing provider may require a note from the treating provider to excuse a late cancellation or no-show due to illness or hospitalization. Failure to provide such documentation may result in the evaluation being terminated. These notes can be faxed to Collin Testing at 828-202-3231.

Court Appearances

In the event that the clinician's appearance is required in connection with a court case (whether civil or criminal), the clinician requires 30 days advance notice for providing deposition or trial testimony. This notice allows for the clinician to arrange their schedule and adequately prepare for testimony. By signing this document, I agree to provide 30 days advance notice. I further agree that any shorter notice would fail to allow a reasonable time for compliance and subject the clinician to undue burden and (potentially) expense.

In the event that I or my counsel requires the clinician's testimony without providing advance notice as described above, I further agree to reimburse any attorney fees Collin Testing incurs in association with objecting to the untimely subpoena.

Third-party informants

A collateral informant for a psychological evaluation is someone who provides information for a psychological evaluation. This could be a family member, friend, teacher, therapist, and/or other professional who knows the person being evaluated (the client). Collateral informants can be extremely helpful to the evaluation process, and you will likely be given a hyperlink to send to these third-party informants to complete an online questionnaire to inform the evaluation process.

I understand that including any third-party informants in the evaluation is voluntary, and I am not obligated to include any third parties in the evaluation process.

I understand that I can withdraw consent from a third-party informant at any time during the evaluation process by communicating with the clinician both orally and in writing. If the request is made before the clinician has had time to read the responses, then the clinician will delete this informant’s information and not consider it in the psychological evaluation process.

I understand that I have can request revisions and/or corrections, including the removal of information provided by third-party informants. While an updated report may be provided within 60 days of the request, diagnoses and treatment recommendations may not be changed. I acknowledge that previously-released copies of the report cannot be retrieved or altered.

I understand that after I receive my psychological evaluation report, I can request corrections/revisions revisions, including the removal of information provided by third-party informants during the evaluation process.

I understand that if I request removal of information provided by any third-party informant, an updated copy may be provided within 60 days of the request. However, I also acknowledge that diagnoses and treatment recommendations influenced by that third-party informant’s disclosures may not be changed.
I also understand that Collin Testing and Psychological Services may have already sent copies of the report, as consented by me or my legally responsible person prior to this request, that include the third-party information, and those previously released copies cannot be retrieved or altered. Therefore, I understand that while the information can be removed from future reports, it may still exist in previously released versions.

I understand that forwarding a questionnaire link provided by Collin Testing and Psychological Services to a third party, via any means, constitutes my consent for that individual to participate as a collateral informant in the psychological evaluation even if I do not sign a written release of information form provided on the patient portal.

I understand that if I decide to include a third-party informant in the evaluation process that the information that the third party discloses will be included in the psychological evaluation and evaluation record.

I understand that Collin Testing and Psychological Services provides a disclosure outlining the role of a third-party informant prior to them providing information. While not required, I can provide context to help all third-party informants understand their role in the evaluation.

General Confidentiality Disclosures

I understand that completing online questionnaires thoroughly enhances the evaluation's accuracy. I understand that my decision to provide information via online questionnaires is voluntary and I can decide to stop at any time.

I understand that technical issues may affect data collection. I recognize that completing questionnaires in one sitting is recommended to avoid data loss.

I understand that telehealth sessions may be discontinued if a higher level of care is needed or if I am in a different state than my clinician.
I understand that information disclosed during therapy or testing that indicates potential harm to myself or others may be disclosed without my consent.

Disclosures and Written Records

Information disclosed during sessions and any related written records are confidential and cannot be disclosed without written authorization, except as is otherwise permitted or required by law.

A notice of privacy practices has been provided which further explains HIPAA Rights and state laws concerning disclosure.

Consent to Disclosures for Continuity of Care

By signing this document, I authorize Collin Testing and Psychological Services to forward my psychological evaluation report to the medical or mental health providers and allied health professionals who made a written referral requesting the psychological evaluation to establish continuity of care. I understand that I can revoke this authorization at any time by notifying Collin Testing and Psychological Services that I do not wish to have my report forwarded to the referring provider. I understand that this authorization will be effective for one calendar year from the date this consent to services document is signed. I understand that by signing this document, the person or entity receiving this information may not be required to protect it in the same way under federal privacy law.

Appointing a Representative

If you have a designated person with medical power of attorney or a legal guardian, they can exercise your rights and make decisions about your health information. We will verify their authority before taking any action.

Acknowledgement of Client’s Rights & Responsibilities

I understand that I can withdraw consent for evaluation or therapy services without affecting future care or benefits.

I understand that I will be asked to provide emergency contacts and understand they may be used if necessary. I understand that I can go to the nearest emergency room in the case of a crisis.
I understand that the use or possession of drugs, alcohol, firearms, and weapons is prohibited at the offices of Collin Testing and Psychological Services.
In a medical emergency, I authorize Collin Testing and Psychological Services staff to seek emergency services.

After reading this evaluation, I agree to all the terms outlined in this document. I consent to psychological evaluation and treatment services and understand I may stop or refuse treatment at any time.

Disability Rights Contact Information: Phone: 919-856-2195 / Toll-Free: 877-235-4210 / TTY: 888-268-5525 / Fax: 919-856-2244 / Email: info@disabilityrightsnc.org / Address: 3724 National Drive, Ste 100, Raleigh, NC 27612 / www.disabilityrightsnc.org

Consent to Clinician Use of Artificial Intelligence (AI)

As part of their ongoing commitment to provide the best possible service, your provider has opted to use HIPAA compliant artificial intelligence (AI) assists in generating clinical documentation, report writing, and other tasks. This allows for more time and focus to be spent on interactions with you and/or the client, additional tests, and clinicians time to provide more accurate and well described diagnostic conclusions and treatment recommendations. Your clinician always reviews all of the content produced by AI for accuracy and completeness. The recording and transcript of conversations are kept confidential using HIPAA compliant sources. Collin Testing uses AI in a way that prioritizes the privacy and confidentiality of your personal health information, while providing you with better quality reports treatment notes, and/or therapy. Your session information is strictly used for the purpose of the psychological evaluation or treatment. Your information is subject to strict data privacy regulations and is always secured and encrypted. Stringent business associate agreements ensure data privacy and HIPAA compliance. By signing this form, you consent to the use of artificial intelligence as described. You acknowledge that your participation is voluntary and not a condition of receiving services from your clinician, and that you can withdraw your consent at any time.Please scroll to the end to read the entire text
Consent to Services Therapy
Informed Consent for Psychological Services
Introduction I understand that this document is designed to inform me about the psychotherapy and evaluation processes, potential risks and benefits, and important policies regarding confidentiality, billing, insurance benefits, cancellations, and my rights and responsibilities as a client. By reviewing and signing this agreement, I acknowledge my understanding and acceptance of these terms.
My participation in a psychological evaluation or psychotherapy is voluntary, and I have the right to withdraw from the evaluation or treatment process at any time. If I have any questions while reading through this form and need additional clarification, I can contact the practice at Contact@CollinTesting.com or 828.630.9347.
Psychotherapy Cost
• I understand that psychotherapy includes an initial clinical interview scheduled by the practice, and follow-up appointments are scheduled directly with the clinician.
• I understand that while the practice may provide an estimate of costs, it is ultimately my responsibility to contact my insurance company to verify my coverage, deductibles, and out-of-pocket costs.
• I will notify the practice as soon as possible of any insurance changes to ensure accurate cost estimates.
• I understand that some plans may not cover psychotherapy, and in these cases, I am responsible for all costs at the self-pay rate of $200 per hour.
Cancellation Policy
• I understand that last-minute cancellations result in significant lost income for the clinician and the practice.
• I understand that rescheduling with advance notice shows respect for the clinician's time and allows the practice to schedule someone else in my place.
• I understand that I can avoid late cancellation and no-show fees by notifying my clinician as soon as possible when I cannot make an appointment.
• I understand that I can talk to my clinician about emergencies or circumstances which may result in waiving a cancellation fee.
• Non-Medicaid Clients: If I do not have Medicaid coverage, I must keep a valid credit or debit card on file. I understand that cancellations made with less than 24 hours' notice, or no-shows, will incur a $200 fee charged to this card. If my card is declined, I must pay all outstanding fees before rescheduling.
Court Appearances In the event that the clinician's appearance is required in connection with a court case (whether civil or criminal), I understand that the clinician requires 30 days advance notice for providing deposition or trial testimony. This notice allows the clinician to arrange their schedule and adequately prepare. I agree to provide 30 days advance notice and understand that shorter notice would fail to allow reasonable time for compliance and subject the clinician to undue burden and expense.
• I agree to pay the clinician's hourly rate of [Insert Hourly Rate Here] for all time associated with legal proceedings, including preparation, travel, and testimony, as these fees are generally not covered by insurance.
• If I or my counsel requires the clinician's testimony without providing advance notice as described above, I agree to reimburse any attorney fees the practice incurs in association with objecting to the untimely subpoena.
General Confidentiality & Written Records Information disclosed during sessions, testing, and any related written records are confidential and cannot be disclosed without my written authorization, except as otherwise permitted or required by law. I acknowledge that a notice of privacy practices has been provided to me which further explains my HIPAA rights and state laws concerning disclosure.
I understand that confidentiality may be broken without my consent in certain legal or emergency situations, including:
• Information indicating potential harm to myself or others.
• Suspected child abuse or neglect.
• Suspected elder or dependent adult abuse.
• A direct court order signed by a judge.
• I understand that telehealth sessions may be discontinued if a higher level of care is needed or if I am located in a different state than my clinician.
Communication Policy I understand that standard email and SMS text messaging are not entirely secure forms of communication. I agree to avoid sharing sensitive medical or personal health information through these channels to protect my privacy.
Appointing a Representative I understand that if I have a designated person with medical power of attorney or a legal guardian, they can exercise my rights and make decisions about my health information. The practice will verify their authority before taking any action.
Acknowledgement of Client’s Rights & Responsibilities
• I understand that I can withdraw consent for evaluation or therapy services without affecting future care or benefits.
• I understand that I will be asked to provide emergency contacts and understand they may be contacted if necessary.
• I understand that I can go to the nearest emergency room in the case of a crisis.
• I understand that the use or possession of drugs, alcohol, firearms, and weapons is prohibited at the offices of the practice.
• In a medical emergency, I authorize the practice staff to seek emergency services.
Consent to Clinician Use of Artificial Intelligence (AI) As part of their ongoing commitment to provide the best possible service, my provider has opted to use HIPAA-compliant artificial intelligence (AI) to assist in generating clinical documentation, report writing, and other tasks. This allows for more time and focus to be spent on interactions with me, additional testing, and providing accurate, well-described diagnostic conclusions and treatment recommendations.
• I understand my clinician always reviews all of the content produced by AI for accuracy and completeness.
• The recording and transcript of conversations are kept confidential using HIPAA-compliant sources.
• The practice uses AI in a way that prioritizes the privacy and confidentiality of my personal health information.
• My session information is strictly used for the purpose of my psychological evaluation or treatment. It is subject to strict data privacy regulations and is always secured and encrypted through stringent Business Associate Agreements (BAAs).
Please scroll to the end to read the entire text
By signing below, I certify that I have read the entire consent to services document and agree to the terms and conditions outlined in the text.

Unfortunately, we do not accept your insurance plan at this time.
You are reading this because you selected an other insurance payer that we do not accept or you selected that you have United Healthcare Medicaid. We no longer accept UnitedHealthcare Medicaid. If you currently have this plan and want your psychological testing covered, please call the NC Medicaid Enrollment Broker at 1-833-870-5500. You can request to switch to an in-network Medicaid plan by stating you are changing due to a lack of access to psychological testing services.

Privacy Policy
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Collin Testing and Psychological Services (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.

 
YOUR RIGHTS

Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.

 
To inspect and copy PHI. You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee. The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.

To amend PHI. You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request. The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.

To request confidential communications. You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.

To limit what is used or shared. You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer. You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.

To obtain a list of those with whom your PHI has been shared. You can ask for a list, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.

To receive a copy of this Notice. You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

To choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.

To file a complaint if you feel your rights are violated. You can file a complaint by contacting the Practice using the following information: Collin Testing and Psychological Services PLLC Katherine Collin 828-630-9347

 
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. The Practice will not retaliate against you for filing a complaint.

 
To opt out of receiving fundraising communications. The Practice may contact you for fundraising efforts, but you can ask not to be contacted again.

 
OUR USES AND DISCLOSURES
1. Routine Uses and Disclosures of PHI The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:

 
To treat you. The Practice can use and share PHI with other professionals who are treating you. Example: Your primary care doctor asks about your mental health treatment.

 
To run the health care operations. The Practice can use and share PHI to run the business, improve your care, and contact you. Example: The Practice uses PHI to send you appointment reminders if you choose.

 
To bill for your services. The Practice can use and share PHI to bill and get payment from health plans or other entities. Example: The Practice gives PHI to your health insurance plan so it will pay for your services.

2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:

To help with public health and safety issues Public health: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication. Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information. Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws. Serious threat to health or safety: To prevent a serious and imminent threat. Abuse or Neglect: To report abuse, neglect, or domestic violence.

 
To comply with law, law enforcement, or other government requests Required by law: If required by federal, state or local law. Judicial and administrative proceedings: To respond to a court order, subpoena, or discovery request. Law enforcement: For law locate and identify you or disclose information about a victim of a crime. Specialized Government Functions: For military or national security concerns, including intelligence, protective services for heads of state, or your security clearance. National security and intelligence activities: For intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law. Workers' Compensation: To comply with workers' compensation laws or support claims.

 
To comply with other requests Coroners and Funeral Directors: To perform their legally authorized duties. Organ Donation: For organ donation or transplantation. Research: For research that has been approved by an institutional review board. Inmates: The Practice created or received your PHI in the course of providing care. Business Associates: To organizations that perform functions, activities or services on our behalf.

3. Uses and Disclosures of PHI That May Be Made With Your Authorization or Opportunity to Object Unless you object, the Practice may disclose PHI:

To your family, friends, or others if PHI directly relates to that person's involvement in your care. If it is in your best interest because you are unable to state your preference.

4. Uses and Disclosures of PHI Based Upon Your Written Authorization The Practice must obtain your written authorization to use and/or disclose PHI for the following purposes:

Marketing, sale of PHI, and psychotherapy notes.

You may revoke your authorization, at any time, by contacting the Practice in writing, using the information above. The Practice will not use or share PHI other than as described in Notice unless you give your permission in writing.

OUR RESPONSIBILITIES

The Practice is required by law to maintain the privacy and security of PHI. The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law. The Practice reserves the right to amend Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above, or by viewing a copy on the website https://collintesting.com. The Practice will inform you if PHI is compromised in a breach.

This Notice is effective on January 5, 2025.Please scroll to the end to read the entire document
By signing below, I certify that I have read the entire privacy policy and understand the terms and conditions.

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