Psychological Evaluation Packet

1

Patient Information

Entered once, used by every consent in this packet.

Patient full name

Date of birth

Phone number

Email

Street address

City

State

ZIP code

2

Consent to Treat

Permission for psychological treatment services.

I consent to participate in psychological treatment services provided by "A Growth Mentality Psychological Services, Inc." I understand that therapy is a collaborative process and that treatment may involve discussing personal issues, setting therapeutic goals, and using evidence-based interventions.

I understand that I have the right to participate in my treatment planning and to refuse or terminate treatment at any time. I acknowledge that therapy is not guaranteed to yield specific results and that progress may vary.

Confidentiality

I understand that information shared in therapy sessions is confidential and will not be disclosed without my written consent, except in cases of potential harm to myself or others, suspected abuse or neglect, or as required by law.

Emergency Contact

In case of emergency, please contact:

Full name

Relationship

Phone number

I have read and understood the above information and consent to receive treatment.

Type your full name as your signature

Signature

3

Consent for Psychological Evaluation

What the evaluation covers and how results are used.

4

Release of Information

Optional. Authorize records to be shared.

Do you want to authorize a release of information now?

5

Patient Rights

Read and acknowledge your rights as a patient.

As a patient at "A Growth Mentality Psychological Services, Inc.", you have the following rights:

1
Right to Respect and Dignity: You have the right to be treated with respect, dignity, and consideration at all times.
2
Right to Confidentiality: Your personal and health information will be kept confidential, as outlined in our privacy practices. We adhere strictly to privacy laws and will not disclose your information without your consent unless required by law.
3
Right to Informed Consent: You have the right to receive information about your treatment, including potential benefits and risks, and to give informed consent before any treatment is provided.
4
Right to Participate in Treatment: You have the right to actively participate in your treatment planning and to make decisions regarding your care.
5
Right to Refuse Treatment: You have the right to refuse any treatment or therapy at any time, understanding the potential risks of such refusal.
6
Right to Access Your Records: You have the right to access and obtain copies of your treatment records, subject to legal limitations.
7
Right to Voice Concerns: If you believe your rights have been violated or if you have any concerns or complaints about your treatment, you have the right to voice these concerns without fear of retribution. You may file a complaint with the practice or with relevant state or federal agencies.

I acknowledge that I have received a copy of this Patient Rights document.

Type your full name as your signature

Signature

The Evaluation Packet, Done Online.

Before you begin

About 10 minutes

No paperwork needed