Psychological Testing Consent Form - Mill Springs Academy

Psychological Testing Consent Form

Dr. Alexandra Pillat, from One Life Child Development Center, is working as an Educational Consultant for Mill Springs Academy. Dr. Pillat will be conducting abbreviated psychological evaluations that will specifically look at students’ cognitive, academic, and social/ emotional/ behavioral functioning. These measures will be completed at Mill Spring Academy and remotely via online parent questionnaires. This evaluation does not replace a full, comprehensive psychological evaluation. Therefore, this abbreviated testing will not provide a specific DSM-5 clinical diagnosis. The information from these measures is meant to inform students’ academic plans at Mill Springs. Dr. Pillat will conduct a short, virtual feedback session with parents to discuss the testing results. A written summary of scores and recommended accommodations will be provided to Mill Springs Academy and to parents.

The cost for the abbreviated psychological evaluation is $1,000. Payment for testing will be made directly from Mill Springs Academy with Mill Springs Academy covering $500 of the testing and parents/guardians covering the remaining $500. Mill Springs Academy will invoice parents/guardians for the $500 through FACTS.

Parent/Guardian Namerequired

First Name

Last Name

Parent/Guardian Email Addressrequired

Student Namerequired

First Name

Last Name

I agree to pay for the parent/guardian portion of testing ($500) with the understanding that Mill Springs Academy will cover the remaining $500.required

Yes

By typing in your name below, you agree to the use of an electronic signature and agree to allow Dr. Pillat to evaluate your child.required

Parent/Guardian First and Last Name

Daterequired

Must contain a date in M/D/YYYY format

Contact

I understand that I will receive a summary of scores and recommended accommodations based on the testing completed by Dr. Pillat and that a copy of that report will also be given to Mill Springs Academy. If I have any questions about the evaluation, I should contact Mill Springs Academy in order to get in touch with Dr. Pillat. I would like to receive a copy of the report via:

Contact Choice

Email (By checking this option, I acknowledge the risks that email is not a secure mode of communication.)

Fax

Mail

Fax Numberrequired

Mailing Addressrequired

Video

Dr. Pillat may video record my child’s assessment for security purposes. Dr. Pillat may share video clips of the testing session to parents during the feedback session to demonstrate a child’s behaviors, skills, or difficulties. This video may also be viewed by staff at Mill Springs Academy. This video cannot be used for any other purposes, unless specified by parents.

Video Choicerequired

I agree to the video consent.

I do NOT agree to the video consent, and do not want my child to be tested.

Supplemental Testing

This evaluation does not replace a full, comprehensive psychological evaluation. Therefore, this abbreviated testing will not provide a specific DSM-5 clinical diagnosis. If parents are interested in confirming a DSM-5 diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder (Autism), Dr. Pillat is offering two supplemental testing packages. Please indicate if you are interested in receiving either option. Payment for the supplemental testing is covered directly by parents. Payment includes the additional report write-up and written DSM-5 diagnostic impressions. Dr. Pillat will review the results of this additional testing during a virtual feedback call with parents. The additional ADHD testing will assess for inattention, hyperactivity, and executive functioning. These measures will be completed at Mill Spring Academy and remotely via online parent and teacher questionnaires. The fee for this additional ADHD testing is $300. The additional autism testing will assess for social communication, social interaction, and behaviors via the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2), which will be conducted at Mill Springs Academy. The fee for this additional autism testing is $500.

I am interested in and agree to pay for the additional Autism evaluation ($500)required

Yes

I am interested in and agree to pay for the additional ADHD evaluation ($300)required

Yes

By typing in your name below, you agree to the use of an electronic signature and agree to the choice of additional testing as chosen in the questions above. Supplemental testing cost(s) will be billed through your student's MSA FACTS account.

Parent/Guardian First and Last Name