Pediatric Informed Consent Form

Please fill out the form below or download the Pediatric Informed Consent Form with the button above and fill it out at your convenience. Please email us if you have any questions. You can send completed paper forms to:

403 W. Cool Dr.
STE 107
Tucson, AZ 85704

or fax to:
520.329.8311

  • Purpose of Evaluation:

    Your child will be undergoing a comprehensive neuropsychological evaluation to clarify diagnostic considerations and identify cognitive strengths and weaknesses, as well as assess emotional, social, and behavioral functioning. As part of this process, you and your child will be interviewed to gather information regarding medical, social, and educational history, as well as any other factors that may influence your child’s functioning. Information may also be gathered (with your permission) from your child’s teachers or other individuals involved in their education or treatment. A report will be generated that encompasses findings and recommendations from the evaluation that may be used at your discretion. The report can be released to other professionals by our office with your written consent. This evaluation is for clinical purposes only and is not intended for forensic purposes.

    Limits of Confidentiality:

    I understand that psychological / educational / medical information can only be released with my signed consent except under the following conditions (and are explained further in the HIPAA Notice Form that will be available upon request)

    • Such information may be sent to assist in processing the insurance claim(s);
    • Such information may be sent in response to a court order;
    • Such information may be sent when the patient has threatened harm to him / herself or to others;
    • Such information may be sent in response to suspected child or elder abuse;
    • Such information may be sent in defense of psychological practice.

    Consent for Evaluation:

    Decisions about psychological, medical, and/or education care, etc. must be made by the child’s legal guardian(s), who must provide consent for the evaluation. Written consent for the evaluation from the parent(s) or legal guardian(s) of the minor child is required to proceed with the evaluation. In the event of parental separation or divorce, where both parents retain legal decision making authority, both parents must consent in writing to this evaluation. If one parent retains sole legal/ decision making authority, this parent must provide our office with legal documentation attesting to this.

    By signing below, you understand and agree with the nature and purpose of this assessment, limits of confidentiality, and have the legal authority to provide consent; and agree to proceed with the evaluation. You may discuss any questions regarding this form with our office or the psychologist at any time.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

By clicking the submit button, you authorize the transmission of your personal health information to be sent over email. We take every effort to ensure that your information stays safe. All information is double encrypted and password protected.