• Psychological Evaluation Consent Form

    Please complete all sections to provide consent for psychological evaluation and related services.

  • Client Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Parent / Guardian Information

  • Format: (000) 000-0000.

  • LIMITS TO CONFIDENTIALITY/PRIVACY: I understand that all information about the above-named client is
    considered private and will not be shared with anyone without my consent, except under the following
    circumstances:

    •   A Core Connection is required to report suspicion of child/elder/disabled adults abuse & neglect.
    • A Core Connection is required to release information for the purpose of abuse/neglect investigations.
    • A Core Connection is allowed to warn potential victims if we believe that their lives are in danger.
    • A Core Connection is required to release a copy of records and/or testimony if subpoenaed in court.

    Even with your consent, A Core Connection will share only the information that is necessary for assessment, coordination of treatment, notification to those responsible for mandated treatment, or other specified purposes as described in the PCP Notification and Release of Information forms.


    STATEMENT OF AUTHORITY TO CONSENT: I certify that I have the legal authority to consent to mental health treatment, release of information, and all legal issues involving the above-named client. If my status as legal
    guardian should change, I will immediately notify A Core Connection of the name, address, and telephone number of the person who has assumed guardianship of the above-named client.


    CONSENT FOR TREATMENT AND TREATMENT LOCATION: I consent for the above-named client to participate in a mental health assessment through A Core Connection, including sharing relevant confidential information with those involved in services.

    • Dependency Case Managers
    • Other Case Management or Treatment Professionals.

    FUNDING AUTHORIZATION: I authorize A Core Connection to release relevant confidential information to my current funding source in order to process claims, obtain reimbursement, and comply with the funding source’s auditing requirements. I understand that I will be responsible for any charges that this funding source does not cover, including any services provided after my insurance has lapsed, fees described on the Copayment Agreement, and fees described in the No Show/Cancellation Policy.


    I understand that I may revoke consent for the above at anytime, however, I cannot revoke consent for action that has already been taken.

    A copy of this release shall be valid as the original. THIS CONSENT EXPIRES 1 YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED

  • Report Delivery Preference*

  • Acknowledgment and Signatures

  • Consent and Acknowledgment:
    By signing below, I acknowledge that I have carefully read and reviewed all information contained in the attached consent packet, including all outlined pages. I understand the nature of the services, policies, and procedures described therein. I have had the opportunity to ask questions and have received satisfactory answers. I voluntarily consent to the services and agree to comply with the guidelines and terms presented. I understand that this consent packet is valid for one year from the date signed, unless otherwise specified or revoked in writing. After one year, the consent will expire, and a new consent will be required to continue services.

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