Contract for Assessment and Diagnostic Services

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Contract for Assessment and Diagnostic Services

Welcome to The Southfield Center for Development. Please take a few moments to thoroughly review this form as it contains important information regarding our office policies and procedures. Please feel free to jot down any questions so that they may be fully discussed. Once you sign this form, it will constitute a binding agreement between us.

The testing process consists of various assessments that examine different facets of a person’s functioning. Testing typically involves question-and-answer, paper-and-pencil or computer-based assessments conducted in a one-to-one setting with the examiner. No single test can predict performance across a variety of environments. The only way to gain accurate results is to administer several tests that help to determine how information is processed under various circumstances. Once all of the data is gathered, a lengthy and complex interpretation process must be conducted before final results are available. This interpretation process typically takes several hours to complete, depending on the type of evaluation. Upon completion of the interpretation the report is written and then a feedback session is scheduled with the responsible party. Depending on the age of the child being evaluated, we may also schedule a second feedback session so that the evaluation results may be explained to the child directly.

When a person is referred for testing, typically the results are needed as quickly as possible. We are very respectful of this need and will do everything in our power to complete the testing and interpretation process in an expedient fashion. While there is sometimes a delay in setting up the first appointment, clinical time has already been set aside to interpret the data once the testing process begins. Once this process is complete, the tester will provide a full report summarizing all results and will meet with all concerned parties to fully explain the results. After this meeting, the tester will ask that you spend some time to review the report. Only after your review will copies of the report be sent to any parties (school, other doctors, etc.) that you designate.

Types of Evaluations:

  1. Psychoeducational testing is a complex set of evaluation procedures that can provide important information regarding a person’s cognitive strengths and weaknesses, academic skills, memory and attention capabilities, and emotional functioning.
  2. Neuropsychological tests are specifically designed tasks used to measure the integration of higher level psychological and neurological functions known to be linked to particular brain structures. This testing is particularly relevant when assessing neurodevelopmental disorders, developmental delay or brain injury.
  3. A Speech and Language evaluation will provide important information regarding a person’s strengths and weaknesses in many different language processing domains. Areas might include: articulation, voice, oral motor, stuttering, receptive language, expressive language, auditory processing, pragmatics, and syntax.
  4. Occupational & Physical Therapy evaluations examine a child’s motor, visual perceptual and sensory development. Many of the ways that our therapists evaluate a child are through observations during typical life activities set up for the child in a Sensory Gym. The child may be provided with standardized tests that compare the child’s development of strength, balance, motor skills and sensory integration to other children of the same age.
  5. A Psychiatric evaluation is a medical evaluation that determines the presence of a psychiatric diagnosis. Results from the evaluation can inform a treatment plan, which may include medication.
  6. Educational testing is conducted by a school psychologist or educational specialist aimed at identifying your child’s specific strengths and weaknesses in the areas of reading, writing, and mathematics. By better understanding their academic needs, professionals will be able to develop educational plans, evaluate existing plans, and provide important information regarding whether a child has demonstrated with academic growth I improvement in response to specific interventions.
  7. Multi-disciplinary testing is a complex set of evaluation procedures that can provide important information regarding a person’s strengths and weaknesses in many areas. Multidisciplinary evaluations are completed by several different clinicians in the specific areas of identified concern (i.e., psychological, language, sensory, and I or educational).

Depending upon the type and extent of the evaluation that you seek, testing may last one hour (i.e., for an occupational therapy evaluation) to twelve hours (i.e. for a multidisciplinary evaluation), broken up over one to four visits. In addition, gathering information regarding a child’s functioning in other settings (home, school, work, and social) is also critical to the overall evaluation procedure. The findings are based primarily upon what the tester observes and evaluates as well as reports of behavior in these other settings. Additionally, especially when working with school-related concerns, it is often necessary for you to provide us with other information, including: copies of all prior evaluations, standardized test results, school records, and teacher reports. While we do not need this information prior to testing, it is necessary that you bring this with you to the first testing session.


The number of testing sessions will be detailed in your Evaluation Plan. The length of the evaluation depends on the type of evaluation and your specific concerns. Please note that since evaluations are tailored individually and each person completes testing in a unique fashion, it is sometimes difficult to predict the exact length of the evaluation as it will depend on your child and his/her ability to sustain attention and energy. After the first testing session, we can inform you more clearly if additional sessions may be necessary.

Once the appointment hours are scheduled, you will be expected to pay a deposit which is nonrefundable and will hold your testing dates. If you need to change the appointment times, we will do our best to accommodate you. However, in that many testing slots are often booked months in pg. 3 advance, there may be a delay in time before we can reschedule.

Illness Policy:

For the well-being and protection of all children being served at the Southfield Center for Development, please reschedule your child’s testing session if he or she has had a fever or other contagious illness such as strep throat or stomach flu within 24 hours of scheduled session. If your child is taking penicillin or antibiotics, please make sure they have been on them for at least 24 hours before coming in for testing. Professional Fees: The fees are based upon the type of evaluation and the amount of time necessary to perform the intake, complete the testing, interpret the data, review appropriate history, write the reply, and discuss the results. Fees and payment schedule will be discussed with you on the date of your intake and will be detailed in your Evaluation Plan.

If additional testing is required that includes practitioners from other disciplines, the fee will change. Additional testing will only be conducted with prior, written approval of the parents.

If a complete evaluation is not necessary, the charge will be based upon the actual time spent in the evaluation process (i.e., time spent testing and time spent scoring, interpreting, and writing results), and will be discussed with you in advance of the first session.

In addition to the testing process described above, it is our practice to charge for other professional services that you may request. This includes telephone contacts with parents, doctors, teachers, lawyers or other involved parties that last longer than 10 minutes; attendance at school meetings and observations of the child in school also are charged according to our hourly rate. In cases where you request additional letters to be provided or summaries of the report to be provided to concerned parties, these services will be billed at an hourly rate as applicable and prorated when necessary.

Insurance Issues:

If you are covered by health insurance, in certain circumstances portions of this testing will be covered. Accessing these benefits is often confusing and we will assist you in any way we can so that you can receive your entitled benefits. This will often include completing treatment request forms; participation in telephone review meetings; and assisting with the preauthorization process. If the requested process involves more than 10 minutes of professional time, this time will be billed accordingly.

Please be aware that the services are being provided to you and not your insurance company. Therefore, you are expected to pay for the services provided and await reimbursement from your company.

We strongly encourage you to take some time to speak with your insurance company about the certification process. Due to the substantial limitations that would be placed on the services, we are not a preferred provider with any insurance company at this time. However, you should contact your insurance company directly and inform them that you are seeking testing services from licensed and/or certified professionals at the Southfield Center. Explain to your insurance company that you are seeking out-of-network benefits for the services to be covered. You will need to give your company specific procedure codes, referred to as CPT codes in order to determine what benefits are available.

In most cases, insurance coverage does not apply to school-based issues. Therefore, it is advisable to speak with your clinician about the person’s evaluation needs and the ways that testing addresses medical and neurological issues. If you can arrange for a medical doctor to recommend the testing, this can sometimes help to support your request. Document all contact with your insurance company as you often need it to have them act upon your claim.

You should also be aware that insurance companies often require you to authorize us to provide a clinical diagnosis, and sometimes extensive clinical information before they will pay for the services. This information will become a permanent part of the insurance company record. All companies are required by law to keep this information confidential; but once the information is in their hands, we have no control over what they do with it. We will attempt to limit what is released to an insurance company and if requested will review information with you prior to its release.

Confidentiality of Records:

In most situations, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this testing contract provides consent for those activities.

There are some exceptions to this policy. In child custody proceedings or other judicial proceedings in which emotional condition is a relevant factor, a judge may require us to release records. Further, if over the course of the evaluation, we uncover information that leads us to suspect that a child, an elderly person, or a disabled person is being abused, we must file a report with the appropriate state agency. If we believe that a person is threatening serious bodily harm to self or others, we are required by law to take appropriate actions. This may include notifying police, the potential victim(s), or arranging for hospitalization. These situations have rarely arisen in our experience. Should such a situation occur, we will make every effort to fully discuss it with you before taking any action.

Contacting Us:

During business hours, The Southfield Center staff can be reached at 203-202-7654. Due to the clinical work that we do, we are not often immediately available by telephone. When we are unavailable, our telephone is answered by a voice mail that we monitor frequently. We will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform us of some times when you will be available. pg. 5 If you experience an emergency while the Center is closed, please contact your nearest emergency room or call 911.

Permission to Release/Exchange Information Between Southfield Center Practitioners

The Southfield Center for Development is a multidisciplinary child development center that provides diagnostic, therapeutic and educational services in a collaborative environment. Om clinical and administrative team is dedicated to helping children and adolescents achieve their full potential. The exchange of information between Southfield Center providers, including but not limited to psychologists, psychiatrists, social workers, marriage and family therapists, speech pathologists, occupational therapists, learning specialists, education advocates, nutritionists, and executive functions coaches (collectively “Providers”), is part of what allows us to provide the highest level of service to the children and families we serve.

By signing this contract, you authorize information release/exchange concerning your child (or yourself, if you are the client being seen, and are 18 years of age or older), among Southfield Center providers. You understand that this information may be used for the provision of services, exchange of treatment information, diagnosis, progress and historical data, and continuation of the provision of services. You also understand that it is your right to revoke consent at anytime, except to the extent information has been released, obtained, or exchanged as originally permitted.

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