Psychoeducational Testing

Informed Consent & Consent to Release Records

Thank you for your interest in Hill Country School Psychology Services. Please complete the below paperwork to indicate your consent.

Explanation of Services

Licensed Specialists in School Psychology (LSSP) and Speech-Language Pathologists (SLP) work with school staff to help students succeed academically, socially, and emotionally. These professionals examine issues that may be contributing to student difficulties and work to find the best solution for each student and situation. Professional staff are credentialed by the Texas State Board of Examiners of Psychologists and the State Board of Examiners for Speech-Language Pathology and Audiology to provide these services.

Reason for Request of Services

The student is being referred for evaluation/consultation by school staff and/or parent for the following reason(s):

To determine whether the student has a disabling condition (such as a Learning Disability (including Dyslexia/Dysgraphia), Autism, Speech and Language Impairment, etc.) that negatively impacts the student’s academic progress and to determine eligibility under Texas Education Agency areas of eligibility.

Nature and Purpose of Proposed Services

Based on the referral, the following may be assessed:

Psychological Evaluation- A psychological evaluation will be completed and the LSSP will endeavor to include information from the parent(s)/guardian, school staff and the student gathered via forms, questionnaires, interviews, and direct face-to-face testing with the student. The evaluation may include cognitive and/or academic ability assessment which typically includes an individually administered intelligence and/or achievement test. Information from other private or school reports, etc. may be included in the psychological evaluation report. You will be provided a copy of the report as well as afforded an opportunity to discuss its findings.
Speech/Language Evaluation- Evaluation of receptive, expressive, and pragmatic language, speech production, fluency, and/or voice.

Purpose/Goals of Service

The purpose of the evaluation is to determine the existence of a disabling condition and to assist in the development of academic and behavioral strategies/goals/objectives.

Confidentiality

Licensees utilize business practices and provide services in a manner that safeguards the privacy and confidentiality of patients and clients. Licensees must inform their patients or clients about confidentiality and foreseeable limitations on confidentiality created by existing and reasonably foreseeable circumstances prior to the commencement of services as part of the informed consent process described in Board rule §465.11 of this title (relating to Informed Consent/Describing Psychological Services). Licensees keep patients and clients informed of all changes in circumstances affecting confidentiality as they arise. Licensees comply with Chapter 611 of the Texas Health and Safety Code and all other state and federal law applicable to patient/client confidentiality. Licensees disclose confidential information without the consent of a patient or client only in compliance with applicable state and federal law. Licensees who release confidential records relating to a patient or client that also contain confidential information relating to a second patient or client that the licensee obtained through the provision of services to that second individual, and who lack consent or other legal authority to disclose the second individual's identity and/or records, must remove all identifying and confidential information relating to the second individual before releasing the records. Licensees may share information for consultation purposes without consent only to the extent necessary to achieve the purposes of the consultation. Licenses shall exclude information that could lead to the identification of the patient or client. Licensees shall not require a patient or client to waive a legal right to confidentiality as a condition of providing services. Licensees include in written and oral reports and consultations, only information germane to the purpose for which the communication is made.

Reference: Texas State Board of Examiners of Psychologists Act and Rules; Rule 465.12. Privacy and Confidentiality.

Maintenance, Control, and Retention of Records

Licensees shall maintain records in a manner that protects the confidentiality of all services delivered by the licensee. Licensees are responsible for the contents of, as well as the access, retention, control, maintenance, and destruction of all records unless stated otherwise by law. Licensees shall make all reasonable efforts to protect against the misuse of any record. Licensees shall maintain control over records to the extent necessary to ensure compliance with all applicable state and federal laws. In situations where it becomes impossible for a licensee to maintain control over records as required by state or federal law, the licensee shall make all necessary arrangements for the transfer of the licensee's records to another licensee who will ensure compliance with state and federal laws concerning records. The possession, access, retention, control, maintenance, and destruction of records of psychological services rendered by a licensee as an employee of or contractor for an agency or organization remain the responsibility of that agency or organization upon the termination of the licensee's employment or contract unless otherwise required by state or federal law or legal agreement. Records shall be maintained and stored in a way that permits review and duplication. Licensees shall comply with all applicable laws, rules, and regulations concerning record retention. In the absence of applicable state and federal laws, rules, and regulations, records, and test data shall be maintained for a minimum of seven years after termination of services with the patient, client, or subject of evaluation, or three years after a patient or subject of evaluation reaches the age of majority, whichever is greater. All records shall be maintained in a manner that permits timely retrieval and production.

Reference: Texas State Board of Examiners of Psychologists Act and Rules; Rule 465.22: Psychological Records, Test Data and Test Materials

In order to proceed with the request for services described, your consent is needed. Please complete the following form to indicate your consent for these services. If major changes in services are proposed, new consent will be required.

Child's Name

First Name

Last Name

Birthdate

YYYY

Parent/Guardian Name

First Name

Last Name

School

Phone

(###)

###

####

Indicate the Type of Evaluation

I approve of verbal and written communication with my child's school and the evaluator to facilitate assessment and the coordination of services.

Agreement to Services

I have agreed to submit my consent by electronic means. By signing my consent electronically, I certify my answers are correct and complete to the best of my knowledge. I also certify that: I have read and understand the service offered for my child. I consent to an evaluation of my child by Hill Country School Psychology Services. I have been fully informed and understand my consent is voluntary and may be revoked at any time. This information will be released/requested upon receipt of my written consent. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. By entering your name in the box below, you are effectively providing your signature, thereby consenting to the service offered by Hill Country School Psychology Services.