Client Consent Form

Client Consent

Client Name:         Date of Birth:        

Insurance Info:

Provider:         Policy Holder:        Policy Number:     

I hereby consent to assessment services provided by the Grandis Evaluation Center, PC. I understand
that I may refuse any or all services at anytime. Services may include, but are not limited to
developmental, mental health, behavior, cognitive, achievement, adaptive and personality assessment,
consultation and/or outpatient therapy. I understand that a written report will be generated from an
assessment and this report will be sent to the referring agency given the proper release of Protected
Health Information is in order. I understand that requests by the undersigned to inspect the report or
receive a paper copy of this report will be made through the referral source. If I am involved in a court
proceeding and a request is made for information about professional services covered under this
consent, such information is considered privileged and cannot be disclosed without further
authorization. This privileged does not apply if I am being evaluated for a 3rd party or the evaluation is
court ordered. (In the case of an emergency I give permission to obtain any emergency services
required. 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 the
Grandis Evaluation Center, PC. I understand its content regarding Client’s Rights and Responsibilities
and my questions about this Professional Services Agreement have been answered.

Client/Legally Responsible Person’s Initials:   Date: 


HIPAA Notice of Receipt of Privacy Practices
• I acknowledge that I have received and read a copy of the Notice of Privacy Practices for services
provided 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 Notice
may be changed in the future and I may request a copy of the new Notice.

Client/Legally Responsible Person’s Initials:   Date: 


Leave this empty:

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Quality Behavioral | Cognitive | Mental Health Assessments
Signature Certificate
Document name: Client Consent Form
lock iconUnique Document ID: f6d651da195eafdd298b93bca482145a4b7d3e6f
Timestamp Audit
March 28, 2018 10:01 pm EDTClient Consent Form Uploaded by Mike Grandis - IP