Bethany Brand, Ph

JESSICA R. SCHWARTING, PSY.D. 28 Allegheny Avenue, Suite 507 Towson, MD 21204 (410) 296-7098 (410) 296-7097 fax Maryland State Licensed Psychologist # 03831

INFORMATION FOR PROSPECTIVE PATIENTS REGARDING PSYCHOLOGICAL ASSESSMENT

General Information I have written out some information in response to frequently asked questions by patients who are receiving a psychological assessment. Please read this information carefully and feel free to ask about anything that is unclear or concerning to you.

A psychological assessment (also referred to as psychological testing or evaluation) usually takes considerable time on both of our parts, often over the course of several days or weeks. During the first session, we will discuss your current and past family and relationship history, any problems or symptoms you are experiencing, any past treatment and its outcome, and other general background information. Over the course of several meetings, we will do a number of different tasks together. You will probably also complete a number of forms and questionnaires on your own. Typically these forms must be completed in my office in order to be valid and usable for an evaluation, although some of them can be completed in my waiting room. When you have completed all the tasks, I will review, score and interpret the results. Occasionally I determine after reviewing some of the material that an additional test(s) would be helpful. If that is the case, I will call you to inform you of this. Most clients want to meet with me for a feedback session to hear about the results of the evaluation. Most clients also give me written permission to send a summary report to their therapist and or other professionals. It is important to understand that we will not be engaging in psychotherapy. Nonetheless, I am still bound by the ethical and legal limitations and laws that any psychologist must follow.

Scheduling: Scheduling presents a special problem because once a given hour is blocked out, it typically cannot be filled again on short notice. I ask that you give me at least three days notice if you need to cancel a meeting. Failure to do so (except in cases of serious illness or emergency) will result in you being billed for the time I scheduled to meet you. Please be aware that fees for missed visits are not covered by insurance.

In the event that I cannot make it into the office due to severe weather, I will change my answering machine message to indicate that the office is closed. If you have an appointment on a day in which the weather is questionable (e.g., many schools have closed), please call my machine before coming to your appointment.

Confidentiality: Maryland laws and the American Psychological Association’s Code of Ethics dictate that information shared with therapists be held in the strictest of confidence. The information obtained in this evaluation is confidential and will not be released without your written consent. Confidentiality is assured in psychotherapy, consultation, and psychological assessments, except in the following situations:

1. You may authorize the release of records or other information to individuals of your choosing. This may be done only with your expressed written consent.

2. Under ethical and legal mandates, I would be required to break confidentiality in the event of clear and imminent danger to yourself or another person. If I believe that a client is threatening serious harm to another, I am required to take protective action which may include notifying the police, warning the intended victim, or seeking the client's hospitalization. If a client threatens to harm himself or herself, I may be required to seek hospitalization for the client.

3. The law requires that mental health professionals disclose to authorities information regarding suspected abuse or neglect of a child or a “vulnerable” adult (e.g., elderly or disabled).

4. There are certain legal situations that may require disclosure of confidential information by court order. Examples specified in Maryland law include: (1) if you are involved in criminal proceedings; (2) legal proceedings related to psychiatric hospitalization; (3) in malpractice and disciplinary proceedings brought against a psychologist; (4) court-ordered psychological evaluations; and (5) certain legal cases where the client has died, (6) child custody, adoption, or other proceedings in which your emotional condition is an important element, and (7) if you choose to include you mental or emotional state as part of any litigation.

Fortunately, these situations rarely arise in my practice. If such a situation should arise, it is my policy to make every effort to fully discuss these matters with a patient before taking any action, unless there is good reason not to do so. While this summary of exceptions to confidentiality should prove helpful in informing you about potential problems, you should be aware that the laws governing these issues are often complex, and I am not an attorney. I encourage our active discussion of these issues; however, if you need more specific advice, you may pursue formal legal consultation.

If you are sending a statement to your health insurance to help cover the cost of this assessment, you should be aware that the insurance company would require information about your treatment and diagnosis before authorizing payment. Since this information would become a part of your insurance file, you may wish to check with your insurance carrier to be sure you are comfortable with the nature of the information that may be requested prior to authorizing billing.

FINANCIAL AGREEMENT

General: In consideration of psychological evaluation being rendered to (Name of patient): ______by Dr. Jessica Schwarting, I, the undersigned, hereby agree to pay for services provided in accordance with the estimated cost of the evaluation as outlined below. I understand that Dr. Schwarting bills an hourly rate for psychological evaluations at a fee of $130 per hour. This rate applies to all telephone calls to myself, my therapist, and any other parties for whom I give her permission to speak. She will also bill for all time in which she: meets with me to do the testing; reviews, scores and interprets the tests; writes the professional report; and meets with us to provide feedback about the results of the evaluation. People vary widely in how much time is needed to complete each task. For this reason, it is not possible to have an exact cost for the evaluation until it is completed. However, Dr. Schwarting estimates that the evaluation will cost between ______and ______. I understand that I must send her ______prior to our first meeting. The estimated balance of ______will be due at the last testing appointment with her. Dr. Schwarting cannot meet with me, nor complete the assessment, including feedback to myself or other professionals, until I have paid the full balance of our bill for the assessment.

I understand that I will initially pay the higher rate of Dr. Schwarting’s estimated charge. Sometimes, the evaluation costs less than this amount, in which case Dr. Schwarting will refund the amount overpaid to her. In some unusual cases, Dr. Schwarting realizes that, based on the length of time already taken to complete the initial tasks, the full assessment will cost more than initially anticipated. She will discuss this with me prior to completing more hours; together we will decide whether we will eliminate some of the tasks or agree to pay a higher cost. If I agree to pay more than was initially estimated, we will write an amendment at the end of this contract. Dr. Schwarting will not charge me more than initially estimated without my permission. However, I understand that if the assessment takes considerably longer than usual, and I chose not to complete all the tasks rather than incur more expense, the assessment results may not be valid. Dr. Schwarting will discuss what, if any conclusions, can be validly drawn from an abbreviated evaluation.

Collection Policy: I understand that if I fail to pay the charges incurred, and Dr. Schwarting must refer my account for collection, that my payment history and the status of my account can be disclosed to a credit reporting agency, a collection agency, court, or an attorney retained by Dr. Schwarting for this purpose. I understand that I will be responsible for any fees related to the collection of my debt (e.g., attorney fees, court costs, collection agency fees).

Signature: ______Date: ______JESSICA R. SCHWARTING, PSY.D. 28 Allegheny Avenue, Suite 507 Towson, MD 21204 (410) 296-7098 (410) 296-7097 fax Maryland State Licensed Psychologist # 03831

CONSENT TO PSYCHOLOGICAL ASSESSMENT

I, ______, agree to participate in a psychological assessment conducted by Jessica R Schwarting, Psy.D. I have been informed by Dr. Schwarting of the nature of this evaluation and I understand that a report will be written based on the results of the evaluation. Dr. Schwarting has informed me that this is considered a medical record that cannot be disclosed to third parties without consent, unless under special circumstances (e.g., possibility of harm to self or others, abuse or neglect of children or vulnerable adults, court-order). I understand that this testing is voluntary and that I can choose to not be tested or to stop testing at any time.

My signature below indicates that I have fully discussed with Dr. Schwarting the various aspects of our contract for a psychological evaluation. Dr. Schwarting has discussed with me scheduling, the nature of the fee and policies regarding missed appointments, and I agree to proceed with the evaluation.

Signature: ______Date: ______

Witness: ______Date: ______