<p> Sheila C. Johnson Center for Human Services 417 Emmet Street South P.O. Box 400270 Charlottesville, VA 22904-4270 www.curry.edschool.virginia.edu/sjc</p><p>Phone: (434) 924-7034 Fax: (434) 924-4621</p><p>Policies and Consent Forms for Assessment Services</p><p>Welcome to the Center for Clinical Psychology Services. The following is an overview of our services and policies. Please review this information prior to your assessment.</p><p>Services and Client Rights </p><p>The Center for Clinical Psychology Services is a training center operated by the Curry Programs in Clinical and School Psychology. Assessment services are provided by University graduate students, who are directly supervised by licensed clinical psychologists, and by University faculty. Psychological and educational assessment services are offered to children, adolescents, college students, and adults.</p><p>The Center for Clinical Psychology Services does not discriminate on the basis of race, color, religion, gender, sexual orientation, gender orientation, national origin, ancestry, age, relationship status, disability, or other individual characteristics. It is important to us that everyone who seeks services at CCPS is treated in a respectful, culturally informed, and welcoming way.</p><p>You have the right to ask questions about the methods used during the assessment. You have the right to refuse the use of specific techniques; you will be informed of the examiner’s intent to use any procedures of significant risk to you.</p><p>You have the right to receive feedback regarding the assessment. If you request it, the written report can be released to any person or agency you desire. The examiner will inform you if he/she believes that making public the assessment findings will be harmful to you and/or your child. It is our policy that written evaluation results cannot be provided until the balance is paid in full.</p><p>Confidentiality</p><p>Information revealed by you, your child(ren), or your family during the assessment process will be kept strictly confidential. However, under certain state and federal laws, disclosure of your or your child’s health information may occur without either your consent or authorization. These may include, but are not limited to, the following circumstances: as required by law; if you or your child are imminently in danger of harming yourself or another person; if a court of law issues a legitimate subpoena; if you or your child is being evaluated by order of a court of law; and if there is currently evidence of physical or sexual abuse of a child. </p><p>The Provider Notice of Privacy Practices describes in detail how personal identifiable medical information about you may be used and disclosed and how you can get access to this information. Please review this information (provided in a separate document) carefully.</p><p>Scheduling Appointments </p><p>The staff at CCPS sees clients by appointment only, and there is typically a long wait for assessment appointments. Please contact us at 924-7034 if you are unable to keep your assessment appointment. Because appointment times are reserved only for you and are scheduled far in advance, it is very important that you call at least 10 days in advance if you are not able to attend your appointment. Missed appointment times prevent us from offering sessions to other clients seeking our services. If we do not hear from you regarding missed appointments, then we cannot guarantee that future appointment times will be held open for you. </p><p>Client Copy - Please keep for your records. Center for Clinical Psychology Services Assessment Policies and Consent Form </p><p>Emergency Communications with CCPS </p><p>CCPS opens at 8am Monday through Friday, and is open until 8pm two evenings per week. During hours when CCPS is closed professional help will be available to you if needed. After 5:00 pm and on weekends, if an emergency should arise that is potentially life threatening, you should contact 911. If the crisis is non-life threatening but requires immediate assistance, you may contact Region 10 Community Services Board at 972-1800. </p><p>CCPS as a Training Site</p><p>The Center for Clinical Psychology Services operates as a service for the community and as a teaching and training program for graduate students in the Programs in Clinical and School Psychology within the Curry School of Education. Interviews and assessment sessions are conducted by University faculty or faculty-supervised students.</p><p>Interviews and assessment sessions held at the Center may be observed by supervising faculty, consultants, and graduate students in training at the Center. All sessions conducted by graduate student examiners must be videotaped for supervisory and training purposes. Videotapes are kept in a locked room and are erased when no longer needed.</p><p>In addition to observation and videotaping at CCPS, assessment procedures ay involve consultation with teachers, counselors or other relevant professionals. These activities allow us to provide you with a comprehensive evaluation.</p><p>Use of Records for Archival Research</p><p>The Center for Clinical Psychology Services periodically conducts archival research to determine large clinical trends. In order to accomplish this, a member of the Center staff reviews records in order to gain specific needed information. The Center staff member notes pertinent information on a data form that is not part of the client’s file and that does not include identifying information. Data will be coded to ensure the confidentiality of your records. All research conducted at the Center receives approval from the UVA Institutional Review Board. Access to coded data derived from the records will be limited to individuals who have received approval from the University of Virginia Institutional Review Board for Studies Involving Human Subjects. </p><p>E-Mail </p><p>E-mail is not appropriate for communicating with the Center since E-mail is not confidential.</p><p>Client Copy - Please keep for your records.</p><p>Updated April 2013 Center for Clinical Psychology Services Assessment Policies and Consent Form </p><p>CLIENT CONSENTS</p><p>Observation/Videotape Consent I understand that all information regarding myself will remain confidential and will not be seen or discussed except by the appropriate staff members associated with the Center. Videotaping is required for all sessions conducted by graduate student examiners. I agree to the following procedures in the Center:</p><p>Observation of my child in school classrooms (if applicable)</p><p>Consultation with teachers, counselors and other professionals</p><p>Observation of myself and/or my child</p><p>Videotaping of myself and/or my child</p><p>Archival Research Consent</p><p>I agree to allow the Center for Clinical Psychology Services to use information from my clinical files for research purposes. </p><p>I do not agree to allow the Center for Clinical Psychology Services to use information from my clinical files for research purposes. </p><p>Consent to be Contacted by Mail and/or Phone</p><p>I agree to have monthly billing statements mailed to the following address:</p><p>______</p><p>______</p><p>I would only like to be contacted at the following phone number(s): Can a message be left at this number? H: ______YES NO</p><p>W: ______YES NO</p><p>Cell: ______YES NO</p><p>Consent to Services and Acknowledgment of Receipt of Notice of Privacy Practices</p><p>I have read the policies document and understand my rights as a client at the Center for Clinical Psychology Services. I have also received the Provider Notice of Privacy Practices. I have completed all portions of the Client Consents page, and I hereby consent to receive treatment through CCPS.</p><p>Client Copy - Please keep for your records.</p><p>Updated April 2013 Center for Clinical Psychology Services Assessment Policies and Consent Form </p><p>CLIENT CONSENTS</p><p>Observation/Videotape Consent I understand that all information regarding myself, my child(ren), and/or my family will remain confidential and will not be seen or discussed except by the appropriate staff members associated with the Center. Videotaping is required for all sessions conducted by graduate student examiners. I agree to the following Center procedures: </p><p>Observation of my child in school classrooms (if applicable)</p><p>Consultation with teachers, counselors and other professionals</p><p>Observation of myself and/or my child</p><p>Videotaping of myself and/or my child</p><p>Archival Research Consent</p><p>I agree to allow the Center for Clinical Psychology Services to use information from my clinical files for research purposes. </p><p>I do not agree to allow the Center for Clinical Psychology Services to use information from my clinical files for research purposes. </p><p>Consent to be Contacted by Mail and/or Phone</p><p>I agree to have monthly billing statements mailed to the following address:</p><p>______</p><p>______</p><p>I would only like to be contacted at the following phone number(s): Can a message be left at this number? H: ______YES NO</p><p>W: ______YES NO</p><p>Cell: ______YES NO</p><p>Consent to Services and Acknowledgment of Receipt of Notice of Privacy Practices I have read the policies document and understand my rights as a client at the Center for Clinical Psychology Services. I have also received the Provider Notice of Privacy Practices. I have completed all portions of the Client Consents page, and I hereby consent to receive treatment through CCPS.</p><p>______Client’s Name Date</p><p>______Signature of Client or Client’s Representative Relationship to Client</p><p>CCPS Copy</p><p>Updated April 2013 Center for Clinical Psychology Services Assessment Policies and Consent Form Client, Please sign and return to Center for Clinical Psychology.</p><p>Updated April 2013</p>