INFORMED CONSENT FOR PSYCHOSOCIAL ASSESSMENT

This document is a disclosure of certain information about the process of a psychosocial assessment. This form will give you information about the assessment process. It details certain rights and responsibilities that you have in this process and gives you some information about me.

The assessment consists of a comprehensive clinical interview, including the use of psychological screening tools. In addition, it may be necessary to review other related materials such as legal, medical, psychological, and educational records, etc. Collateral information may be needed and interviews with physicians or current/former psychotherapists may be necessary.

The goal of this assessment is to obtain information about your past and current personal and psychological status in connection with your immigration case. This consent is for the sole purpose of facilitating an immigration psychosocial assessment and not intended for psychotherapy.

I am not responsible for the outcome of any immigration proceeding in which this psychosocial assessment is submitted. I take no responsibility for any information written in this assessment which differs from the information that you may present in your testimony, declaration, affidavit, or any other communication.

I reserve the right to cancel this contract at any time, for any reason, without prior notification in cases including, but not limited to, non-payment or in the case of malingering.

Your participation in this assessment is voluntary. I will not conduct the assessment without your signature on this document. You have the right to stop the assessment at any time.

 If, at any time, you have a question about any aspect of the assessment, please feel free to ask me. In addition, if at any time you need a break from the assessment, please let me know.

 QUALIFICATIONS

I have been providing psychotherapy to children, adolescents, and adults and conducting psychosocial assessments since 2002. I have a Master of Education from the University of Florida and am a Licensed Mental Health Counselor by the State of Florida Department of Health (License #MH8941). 

RISKS AND BENEFITS

Although psychosocial assessments may provide some therapeutic benefits, they are not therapy.  individuals may benefit from ongoing psychotherapy. If I determine that you may benefit from ongoing therapy, I will provide you with a list of psychotherapists. Every effort will be made to minimize any discomfort that you may experience during the assessment. Nonetheless, you may experience distress and difficulties pertaining to the material you are relating. As this is a collaborative process, we may decide that you would be better served by a different service or another therapist.

 EMERGENCIES

If you have an emergency between our sessions and need immediate help, I recommend that you call 911 or go to your nearest emergency room.

 CONFIDENTIALITY

Your confidentiality is extremely important to me. All information provided during the assessment will be held confidential, except for the written psychosocial evaluation which will be given to you and your attorney. While your privacy is paramount, so is your safety and the safety of others who may be in danger. There are several situations in which I may be legally obligated to break confidentiality:

- If you express intent to seriously harm yourself

- If you threaten serious bodily harm to another person/s

- If there is suspicion or evidence of abuse or neglect of a child, elder or vulnerable person/s

- If compelled by a court order

 In any of the above situations, you and I will first discuss and attempt to come to an agreement on how to proceed. If we are unable to do so in a safe and legal way, I will do so independently and I will take further measures without your permission that are provided to me by law.

If your attorney has requested this assessment, with your written permission, they will receive a copy of the report and will determine how it will be used and who has access to it. Information regarding this assessment may be disclosed to a judge, attorneys, USCIS (United States Citizen and Immigration Services) and other court and agency personnel involved in this case.

Once a decision has been made to use the report in a legal proceeding, the report and any information pertaining to it may be admissible as evidence as well as any other information that was provided concerning your mental health and functioning. If you have any concerns about the use or distribution of this report, you should discuss these issues carefully with your attorney.

Additionally, I will release information to others at your request if you have signed a release of information form for an individual or agency.

CANCELLATION POLICY

Please remember to cancel or reschedule appointments 24 hours in advance. Cancellations and the re-scheduled session will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. 

FEES

Evaluation and Report Fee: The fee for a psychosocial evaluation is $1,200. This includes the structured interview, psychological screening and report writing. An initial deposit of $600 must be paid up front and full payment is required prior to receiving the final signed copy.  I accept cash and credit cards for payment.                                                                                                  Expedited Report Fee: If a completed evaluation and report is needed in less than 2 weeks, an expedited report cost of $300 will be added to the evaluation and report fee.

Court Fees: If I am required to be in court, the time preparing, traveling to, and attending court will have an additional fee of $200 per hour. There is a mandatory deposit of 4 hours of time ($800) that will be required 7 days in advance of going to court. This is non-refundable. If your court case day is moved, please let me know with as much notice as possible so that I can do my best to accommodate your  request. 

Payment: Payment for services can be made through Zelle bank transfer (use rikki@goldenskycounseling.org to find the account).

By signing this document, you are also confirming your understanding that if for any reason, payment is not received, Golden Sky Counseling will submit overdue fees to a collection agency after 30 days if no repayment plan is formally documented/agreed upon. Golden Sky Counseling will make a good faith effort to try and resolve overdue fees before submitted to collections, based upon the contact information you provide.