Paula J. McCall, PhD, NCSP, AZ Licensed Psychologist #4262
Parent/Guardian Consent Form
Description of Services
My signature below provides consent for my child, ______, hereafter referred to as “Client,” to participate in individual counseling sessions with Dr. Paula J. McCall. I understand that counseling sessions will last for 50 minutes at a time and that I will be provided with general information and recommendations related to the counseling sessions so that I can incorporate skills and techniques in the home.
I understand that Dr. Paula McCall’s counseling services may also include psychological evaluation, assessment, consultation, and intervention. I understand that evaluation and assessment services may include the use of psychological assessments, although additional consent will be obtained prior to initiation of a comprehensive evaluation. I understand that intervention services may include counseling along with the use of psychological measures for the purpose of obtaining additional information in the process of treatment planning.
I understand that Dr. Paula McCall is not warranting a cure or offering any guarantee of results or improvement of any condition.
Assumption of Risks and Benefits
Potential benefits of treatment include clarifying diagnosis and/or reducing emotional, behavioral, or relationship problems. I understand that potential risks may include limited predictive validity of psychological assessment procedures, possible disagreement with the opinions offered, and possible emotional distress concerning the Client’s situation. I understand that alternative procedures include services provided by another psychologist, psychiatrist, or mental health professional, or no treatment.
Limits of Confidentiality
Since counseling is based on a trusting relationship between the Client and the psychologist, I understand that many of the details of the counseling sessions will remain confidential unless the Client agrees to the sharing of additional details. However, I also understand that in the following situations confidential information must be shared by Dr. Paula J. McCall to the appropriate contacts. I understand that confidential and privileged information may be released in the following situations without my or the Client’s consent or authorization in the following circumstances recognized by Arizona law and HIPAA:
Child Abuse:If Dr. McCall knows, or has reasonable cause to suspect, that a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver or other person responsible for the child's welfare, the law requires that such knowledge or suspicion is reported to the Arizona Child Protective Services.
Adult and Domestic Abuse: If Dr. McCall knows or has reasonable cause to suspect, that a vulnerable adult (disabled or elderly) has been or is being abused, neglected, or exploited, it is required by law to immediately report such knowledge or suspicion to the Abuse Hotline.
Health Oversight: If a complaint is filed against Dr. McCall with the Arizona Department of Health on behalf of the Board of Psychology, the Department has the authority to subpoena confidential mental health information from Dr. McCall relevant to that complaint.
Judicial or Administrative Proceedings: If I or the Client is involved in a court proceeding and a request is made for information about diagnosis or treatment and the records thereof, such information is privileged under state law, and Dr. McCall will not release information without the written authorization of myself, the Client, and/or our legal representative. The privilege does not apply when I or the Client are being evaluated for a third party or where the evaluation or records request is court ordered. I and/or the Client will be informed in advance if this is the case.
Serious Threat to Health or Safety: When I or the Client present a clear and immediate probability of physical harm to the self, to other individuals, or to society, Dr. McCall may communicate relevant information concerning this to the potential victim, appropriate family member, or law enforcement or other appropriate authorities.
Worker’s Compensation: If I or the Client file a worker's compensation claim, Dr. McCall must, upon request of the employer, the insurance carrier, an authorized qualified rehabilitation provider, or the attorney for the employer or insurance carrier, furnish relevant records to those persons.
I hold Dr. Paula J. McCall harmless for releasing information under any of the above conditions.
Release of Information
I understand that records may be protected under federal regulations including but not limited to HIPAA. By authorizing a release of information, I understand that I am waiving the confidential nature of the patient-psychologist relationship.
I authorize the release of information as necessary for the purpose of Dr. Paula J. McCall obtaining consultation regarding Client’s evaluation or treatment.
If Client is a hospitalized inpatient, I understand and agree that Dr. Paula J. McCall may discuss evaluation and treatment with physician, hospital staff, utilization review staff, and others concerned with Client’s care.
I authorize the release of any and all information requested by my/ Client’s managed care company or insurance carrier for the purpose of processing insurance claims and obtaining payment for services. If Client is entitled to Medicare or managed care benefits, I authorize the release of information to Medicare or to the managed care company.
By authorizing the release of information to an insurance company or other third party, I understand that the information may become part of the third party’s records and that Dr. McCall can no longer control any subsequent release of that information. Dr. McCall has informed me that should I ever authorize a general release of my medical records from an insurance company or other third party, it is possible that the third party’s copy of my psychological records could possibly be released by the third party without Dr. McCall’s knowledge.
I understand that Dr. McCall cannot prevent any hospital, physician’s office, or insurance company from releasing or redisclosing information to the Medical Information Bureau or other agencies or persons. I hold Dr. McCall harmless for any secondary release or redisclosure of my report made by the hospital, the physician’s office, the insurance company, the medical information bureau, or any person or agency to whom the report is originally released.
After giving consideration to the extent of this release, I specifically direct and authorize Dr. Paula J. McCall to exchange confidential information and discuss her opinions with agencies such as a referring physician or insurer or for the purpose of providing information about Client’s evaluation or treatment.
If I or Client is entitled to Medicare Benefits, I authorize Dr. Paula J. McCall to discuss Client’s case with Client’s primary care physician or the physician who referred the Client. I understand that this is a requirement for Medicare reimbursement.
Statement of Understanding and Provision of Informed Consent
By signing this form, I give informed consent for the Client, over whom I have legal rights, to participate in individual counseling and related activities, as described within this document, with Dr. Paula J. McCall. I understand that I have the right to terminate counseling at any time. Unless otherwise requested, this consent will remain active for one calendar year from the date of my signature.
I acknowledge that I voluntarily consent to the preceding conditions and that this consent form is valid during any related claims. I certify that I have read this form or that it has been read and explained to me in terms that I understand. My questions have been answered to my satisfaction and all statements of which I do not approve have been stricken. By signing this form, I understand and agree with the terms and conditions of this form.
Parent/Guardian Name (Printed): ______
Parent/Guardian Signature: ______
Date: ______
Initial: _____