Client Consent Form
Client Name: Date of Birth:
Provider: Policy Holder: Policy Number:
I hereby consent to assessment services provided by the Grandis Evaluation Center, PC. I understandthat I may refuse any or all services at anytime. Services may include, but are not limited todevelopmental, mental health, behavior, cognitive, achievement, adaptive and personality assessment,consultation and/or outpatient therapy. I understand that a written report will be generated from anassessment and this report will be sent to the referring agency given the proper release of ProtectedHealth Information is in order. I understand that requests by the undersigned to inspect the report orreceive a paper copy of this report will be made through the referral source. If I am involved in a courtproceeding and a request is made for information about professional services covered under thisconsent, such information is considered privileged and cannot be disclosed without furtherauthorization. This privileged does not apply if I am being evaluated for a 3rd party or the evaluation iscourt ordered. (In the case of an emergency I give permission to obtain any emergency servicesrequired. I understand that I will be financially responsible for such care).
Client/Legally Responsible Person’s Initials: Date:
Client Rights: I have received and read a copy of the Professional Services Agreement from theGrandis Evaluation Center, PC. I understand its content regarding Client’s Rights and Responsibilitiesand my questions about this Professional Services Agreement have been answered.
HIPAA Notice of Receipt of Privacy Practices• I acknowledge that I have received and read a copy of the Notice of Privacy Practices for servicesprovided by the Grandis Evaluation Center, PC.• I understand that the Notice of Privacy Practices discusses how my protected health information (PHI)may be used and/or disclosed and my rights with respect to my PHI.• I may obtain an additional copy of this Notice at any time. I understand that the terms of this Noticemay be changed in the future and I may request a copy of the new Notice.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Client Consent Form
Agree & Sign