Academic Evaluations (Used when the question is primarily educational.)

  Evaluation Services & Fee Agreement This Document includes your Agreement Form and descriptions of services to help determine what type of testing ...
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Evaluation Services & Fee Agreement This Document includes your Agreement Form and descriptions of services to help determine what type of testing would be most useful.

Psychoeducational / Educational / Academic Evaluations (Used when the question is primarily educational.) Full Psychoeducational Evaluation: This includes an IQ and Achievement battery plus ADHD testing to assess for the possibilities of ADHD and/or learning disabilities, combined with diagnostic interviewing to screen for the influence of depression, anxiety, and other mental health conditions on educational abilities and performance. A complete history is also taken to identify any possible medical conditions that might be affecting educational abilities and performance. The evaluation is broken down into at least two sessions to avoid fatigue for the client and to provide the clearest diagnostic results. Tests: Wechsler Intelligence Scale for Children - Fourth Edition (WISC-IV) IQ Test, Wechsler Preschool and Primary Scale of Intelligence - Fourth Edition (WPPSI-IV) IQ Test, or Wechsler Adult Intelligence Scale Fourth Edition (WAIS-IV) IQ Test (depending on age), Wechsler Individual Achievement Test - Third Edition (WIAT-III), ADHD Testing, screening for behavioral, social, and emotional issues, in-depth clinical interview. Time: 4½ – 5 hours, including clinical interview (testing divided into at least 2 sessions) Cost: $1,660 (Half due at the first evaluation session and the remainder due at the second evaluation session. The final interpretive session is $150. (If a school observation or visit is required, this is billed at an additional $160 per hour, port to port, due in advance.) Intellectual & Achievement Evaluation (Gifted Evaluation/LD Evaluation): Ages 6+. These IQ and Achievement tests will provide in-depth information on several factors of intelligence (such as factual knowledge, short-term memory, abstract reasoning, visual-spatial abilities, and common sense), academic strengths and weaknesses, mastery of specific subjects, and the presence of a learning disability. The results are commonly used by many educational programs to determine if a child meets criteria for a “Gifted” or “Learning Disabled” classification. Tests: Wechsler Intelligence Scale for Children - Fourth Edition (WISC-IV) IQ Test, Wechsler Preschool and Primary Scale of Intelligence - Fourth Edition (WPPSI-IV) IQ Test, or Wechsler Adult Intelligence Scale Fourth Edition (WAIS-IV) IQ Test (depending on age), Wechsler Individual Achievement Test - Third Edition (WIAT-III), clinical interview. Time: 4 – 4½ hours, including a clinical interview (testing divided into 2 sessions) Cost: $1050 (Half due at the first evaluation session and the remainder due at the second evaluation session. The final interpretive session is $150. (If a school observation or visit is required, this is billed at an additional $160 per hour, port to port, due in advance.) ADHD Testing: This includes ADHD testing combined with a full IQ test, clinical interviewing, play-based assessment, and rating scales. Tests: Wechsler Intelligence Scale for Children - Fourth Edition (WISC-IV) IQ Test, Wechsler Preschool and Primary Scale of Intelligence - Fourth Edition (WPPSI-IV) IQ Test, or Wechsler Adult Intelligence Scale Fourth Edition (WAIS-IV) IQ Test (depending on age), Behavior Assessment System for Children - Second Edition (BASC-2), ADHD Rating Scales, clinical interview, play-based assessment. Time: 3 – 4 hours (including 1 hour for a parent interview, 2 – 3 hours for the child or teen assessment) Clinical Evaluation Services And Fee Agreement

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Cost: $980 (Payment due in full at the evaluation session. The final interpretive session is provided free of charge. (If a school observation or visit is required, this is billed at an additional $160 per hour, port to port, due in advance.) Intellectual Testing Only: This includes the Wechsler Intelligence Test, which will provide in-depth information on several factors of intelligence (i.e. factual knowledge, short-term memory, abstract reasoning, visual-spatial abilities, common sense, etc), and on academic strengths and weaknesses. The results are used by educational programs as part of the determination of the “Gifted” label. At the other end of the spectrum, the results can also identify intellectual disability. Tests: Wechsler Intelligence Scale for Children - Fourth Edition (WISC-IV) IQ Test, Wechsler Preschool and Primary Scale of Intelligence - Fourth Edition (WPPSI-IV) IQ Test, or Wechsler Adult Intelligence Scale Fourth Edition (WAIS-IV) IQ Test (depending on age). Time: 1½ – 2 hours (including 20 – 30 minutes clinical interview) Cost: $595 (Payment due in full at the evaluation session. Interpretive session is $150.) Achievement Testing Only: This typically includes the Wechsler Individual Achievement Test - Third Edition (WIAT-III), the standard in assessing academic achievement, which will provide in-depth information regarding a child’s mastery of specific subjects, academic strengths, and weaknesses. Tests: Wechsler Individual Achievement Test - Third Edition (WIAT-III). Test of Early Mathematics Ability Third Edition (TEMA 3) and Test of Early Reading Ability -Third Edition (TERA 3), or Wide Range Achievement Test - Fourth Edition (WRAT 4) can be used as alternate tests Time: 1½ – 2 hours Cost: $595 (Payment due in full at the evaluation session. Interpretive session is $150.) School Consultation: School consultations are designed to assist in identifying a child’s educational and behavioral needs at school and developing and implementing a plan to meet those needs. We may observe your child at school and talk with the teacher(s) to assess concerns and discuss classroom interventions & accommodations. We can attend formal meetings with parents at their child’s school (such as IEP or 504 meetings). You and your child may also attend sessions at our office focused on study and organizational skills and developing a homework contract. Time: Typically 1 hour Cost: $160 per hour, including driving time from the office

Developmental/Speech-Language Evaluations (Used when the question is primarily developmental or language.) Developmental Evaluation / Autism Evaluation: This is a battery of tests and interviews for children ages 5 – 18 when there are concerns about a child’s cognitive, social, emotional, or behavioral development. An IQ test is included in this package. This evaluation can also be used when parents want to determine if their child has a disorder on the Autistic Spectrum. Tests: Wechsler Intelligence Scale for Children - Fourth Edition (WISC-IV) IQ Test, Wechsler Preschool and Primary Scale of Intelligence - Fourth Edition (WPPSI-IV) IQ Test, or Wechsler Adult Intelligence Scale Fourth Edition (WAIS-IV) IQ Test (depending on age), Gilliam Autism Rating Scale - Second Edition (GARS-2), Gilliam Asperger's Disorder Scale (GAD), parent interview, play-based assessment, rating scales, questionnaires. Time: 3 – 5 hours (Typically divided into 2 sessions) Cost: $1490 (Half due at the first evaluation session and the remainder due at the second evaluation session.) The final interpretive session is $150. (If a school/daycare observation or visit is required, this is billed at an additional $160 per hour, port to port, due in advance.)

Clinical Evaluation Services and Fee Agreement

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Multidisciplinary Developmental Evaluation / Autism Evaluation: This is a battery of tests and interviews for children ages 5 – 18 conducted by a team of clinicians when there are concerns about a child’s cognitive, social, emotional, sensory processes, speech and language functioning, and behavioral development. Tests: Wechsler Intelligence Scale for Children - Fourth Edition (WISC-IV) IQ Test, Wechsler Preschool and Primary Scale of Intelligence - Fourth Edition (WPPSI-IV) IQ Test, or Wechsler Adult Intelligence Scale Fourth Edition (WAIS-IV) IQ Test (depending on age), Gilliam Autism Rating Scale - Second Edition (GARS-2), Gilliam Asperger's Disorder Scale (GAD), Mullen Scales of Early Learning, Sensory Profile, Comprehensive Assessment of Spoken Language (CASL), parent interview, play-based assessment, rating scales, questionnaires. Time: 4 – 6 hours (Typically divided into 2 sessions) Cost: $2170 (Half due at the first evaluation session and the remainder due at the second evaluation session.) The final interpretive session is $150. (If a school/daycare observation or visit is required, this is billed at an additional $160 per hour, port to port, due in advance.) Multi-Domain Developmental Evaluation: This is a test battery and interview for children ages Birth – 68 months when there are concerns about a child’s cognitive, gross and fine motor, and expressive and receptive language functioning. Tests: Mullen Scales of Early Learning and parent interview. Time: 2 – 3 hours Cost: $510 (Payment due in full at the evaluation session. Interpretive session is $150.) Comprehensive Speech Evaluation: This is a test battery and interview for children ages 3 – 21yrs when there are concerns about a child’s language processing skills including: comprehension, expression and retrieval. Tests: Comprehensive Assessment of Spoken Language (CASL) and parent interview. Time: 2 – 3 hours Cost: $510 (Payment due in full at the evaluation session. Interpretive session is $150.) Basic Speech Evaluation: This is used to evaluate one specific area of communication. For example, stuttering, voice, or articulation would be areas addressed under this type of evaluation. Tests: Parent interview and selected tests (Tests vary depending on the area of communication evaluated). Time: 1 – 2 hours Cost: $340 (Payment due in full at the evaluation session. Interpretive session is $150.)

Psychological/Neuropsychological Evaluations (Used when the question is primarily psychological or cognitive.) Full Psychological Evaluation: This includes cognitive, emotional and personality testing, and provides indepth information on an individual’s functioning in all three of these areas. It’s useful to help understand what a person is thinking and feeling, underlying personality structure, cognitive strengths and limitations, coping skills and weaknesses, and why a person behaves a certain way. In clinically complex cases and/or cases in which it is difficult for a person to identify or articulate problem areas, a full psychological evaluation can be an invaluable resource for providing diagnostic clarification and treatment recommendations. The evaluation is broken down into at least two sessions to avoid fatigue for the client and to provide the clearest diagnostic results. Tests: Wechsler Intelligence Scale for Children - Fourth Edition (WISC-IV) IQ Test or Wechsler Adult Intelligence Scale - Fourth Edition (WAIS-IV) IQ Test (depending on age), Minnesota Multiphasic Personality Inventory - Second Edition (MMPI-2), Millon Clinical Multiaxial Inventory - Third Edition (MCMI-III), Minnesota Multiphasic Personality Inventory–Adolescent (MMPI-A), Millon Adolescent Clinical Inventory (MACI), or Clinical Evaluation Services and Fee Agreement

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Behavior Assessment System for Children - Second Edition (BASC-2) depending on age, questionnaires, and clinical interview. Time: 4 – 5 hours (typically divided into 2 sessions) Cost: $1,830 (Half due at the first evaluation session and the remainder due at the second evaluation session). The final interpretive session is $150. (If parents want to test for learning disabilities and want achievement testing included as well, the total cost is $2,280.00.) Abbreviated Psychological Evaluation: This includes emotional and personality testing, and provides indepth information regarding an individual’s functioning in both of these areas. This testing helps to clarify what a person is thinking and feeling, underlying personality structure, coping skills and weakness, and why a person behaves a certain way. If previous cognitive testing exists, or if it seems fairly certain that cognitive limitations do not bear on the case, an abbreviated psychological evaluation can be an invaluable resource for providing diagnostic clarification and treatment recommendations. Tests: Emotional and personality testing, abbreviated IQ testing, and clinical interview. Time: 3 – 4 hours Cost: $1,320 (Payment due in full at the evaluation session.) The final interpretive session is $150 Pre-Adoption Evaluation: This includes a clinical interview and personality testing. It provides an overview of each parent’s psychosocial functioning and parent readiness, as well as marital stability. Tests: Clinical interview and Minnesota Multiphasic Personality Inventory - Second Edition (MMPI-2) and/or Millon Clinical Multiaxial Inventory - Third Edition (MCMI-III) depending on adoption agency. Time: 3 – 4 hours Cost: $980 (Payment due in full at the evaluation session. Generally, your insurance will not cover these procedures since they are not considered mental health treatment.) Mental Health Assessment: This assessment will provide an overall picture of emotional, social functioning and ability to think, reason, and remember. Tests: Clinical interview Time: 1 hour Cost: $335 (Payment due in full at the evaluation session.) The final interpretive session is $150 Neuropsychological Evaluation: This evaluation will provide in-depth assessment of cognitive and behavioral functioning using a set of standardized tests and procedures. Mental functions, such as intelligence, problem solving, planning and organization, language, academic skills, perceptual and motor abilities, attention, memory, learning, emotions, behavior, and personality are assessed. Tests: Wechsler Intelligence Scale for Children - Fourth Edition (WISC-IV) IQ Test, Wechsler Preschool and Primary Scale of Intelligence - Fourth Edition (WPPSI-IV) IQ Test, or Wechsler Adult Intelligence Scale Fourth Edition (WAIS-IV) IQ Test (depending on age), the Delis-Kaplan Executive Function System (D-KEFS), the California Verbal Learning Test – Second Edition, (CVLT-II), the California Verbal Learning Test - Children Version (CVLT-C), Trail Making Test A&B, The Rey Complex Figure Test (RCFT), , the Wechsler Memory Scale – Fourth Edition (WMS-IV), the Trail Making Tests A and B, and the Reitan-Indiana Aphasia Screening Test, Children Memory Scales (CMS) Time: 5 - 6 hours, including a clinical interview (testing divided into 2 sessions) Cost: $2000 (Half due at the first evaluation session and the remainder due at the second evaluation session). The final interpretive session is $150. Other Psychological Testing: In some instances, a single or minimum number of tests, such as one personality test, or depression and anxiety screens, may be quite useful in clarifying the diagnosis and thus aiding in treatment planning. Tests: Personality testing, depression screening, anxiety screening, etc. Clinical Evaluation Services and Fee Agreement

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Time: Many of these tests are fairly brief. We will provide you with an estimate of total time involved before testing. Cost: $170 per hour for testing time, scoring, and interpreting the data. (Payment due in advance of testing.) Please indicate the type of evaluation you are requesting. Full Psychoeducational Evaluation: $1,660 Intellectual Testing Only: $595 Full Psychological Evaluation: $1830 Full Psychological + Full Psychoed: $2,280 Pre Adoption Evaluation: $980 Multidisciplinary Developmental Evaluation: $2170 Multi-Domain Developmental Evaluation: $510 Comprehensive Speech-Language Evaluation: $510 Other Psychological/Development/Speech Testing: $170/hr

LD or Gifted Testing: $1050 Achievement Testing only: $595 Abbreviated Psychological Evaluation: $1,320 AD/HD testing: $980.00 Developmental Evaluation: $1490 Neuropsychological Evaluation: $2000 Basic Speech-Language Evaluation: $340 School Observation: $160/hr

What do you hope to learn through this evaluation? _______________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Regarding Estimates of Time: When an hourly fee applies instead of a flat fee, we will provide an estimate of the total number of hours the evaluation will take and the associated cost. Should the evaluation take additional time you will be notified prior to us proceeding with the additional hours. We will require a deposit at the commencement of the evaluation. Regarding Self Pay: We offer a 10% discount for patients paying in full at the time of service without using insurance. Regarding Refunds: We do not offer refunds if you are unhappy with the evaluation, report, clinical suggestions or recommendations. We do not offer refunds if your insurance company refuses reimbursement of our services. We do not offer refunds under any circumstances. Regarding Returned Check Fees: There is a $35 fee for returned or bounced checks in addition to a late fee of 20% monthly. Payment is due in full before the feedback session and/or before the report is released. We charge an extra 10% “Rush Fee” for evaluations requiring results and a report less 2 weeks after the testing has been completed Your signature below indicates you have read this document, the therapist-client services agreement, and agree to abide by their terms during our professional relationship. In particular, please note the following important statements: • Payment as described above is due up front; the evaluation will not begin until payment is received. • The full fee is charged for missed or cancelled sessions, unless you cancel 48 hours in advance. • We do not offer refunds under any circumstances. • Fees apply for bounced checks: amount due + $35 + 20% monthly late fee. I have read and understand the Clinical Evaluation Services and Fee Agreement. I agree to the statements herein and the terms of payment. ___________________________________ Signature of Patient (14 years+)

________________ Date

____________________________ Patient's Name (Printed)

___________________________________

________________

____________________________

Signature of Personal Representative (if different)

Date

Personal Representative (Printed)

Clinical Evaluation Services and Fee Agreement

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