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Psychological Assessment Policies & Procedures |
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Psychological Assessment Services
© UHM CSDC |
Client Name: _______________________________ ID#: __________________ CSDC Assessment Policies and Procedures ______ Eligibility:
I understand that I must be registered either full time or half time to be
eligible for student ______ Fees: Total cost of testing is arranged and agreed upon by Assessment Coordinator and client with option of paying in installments to Joan at the testing office (QLC Room 307) via cash or check. Please make check payable to: University of Hawai‘i at Mānoa. Total payment is due before feedback session can be scheduled and report can be given. ______ Payment: I understand that payment for testing does not guarantee a specific outcome or result, and that the payment is for testing services rendered. ______ No Show/Cancellation Policy: No shows/same day cancellations will result in a $10 fee added onto my total payment due. I may also be dropped to the bottom of the wait list resulting in a significant delay in completing testing.
Assessment Screening Appointment (50 minutes): ______ I understand that an assessment screen is to explore my needs, strengths, and weaknesses as a student and examine a variety of options to increase my academic success. ______ I understand CSDC is limited in the number of assessments that can be provided. Priority is given to students who are in immediate academic need and are in danger of academic disqualification. ______ I understand that learning assessments can be provided by community agencies. They typically can complete an assessment in a much shorter time frame than CSDC. The cost typically ranges from $1500 and above. Any paperwork or other records I have completed at CSDC can be sent to these agencies if I sign a release of information. Reproduction or duplication costs $0.05 per page. _____ I understand that if I am unable to be tested this semester, my place on the wait list the subsequent semester will be affected by how soon I provide my new time schedule and availability. Paperwork to be Completed Before Scheduling an Assessment Intake: ______ Create assessment file (with front desk) ______ Overview of the CSDC Assessment Policies & Procedures (review and sign) ______ Application Form: Background Information ______ Brown ADD (self-report and collateral) ______ Release of information for educational and medical records (as needed) Testing: ______ I understand that once I have returned the completed paperwork (e.g., the background information and/or contract form) to Dr. Sam Khen in suite 312, an assigned assessment counselor will call to schedule an Assessment Intake appointment with you to start the testing process.
______ I understand that individual testing may take anywhere between 4-12 hours to complete depending on presenting issues. I will be given a time slot (usually 2-4 hours long) and I will meet during that time period for several weeks until testing is complete. Testing may take about two to four weeks once it has begun. ______ I understand that I may be tested by a doctoral psychology trainee or a post-doctoral fellow who is supervised by a licensed psychologist.
Feedback: ______ I understand that after testing has been completed and I have paid in full, I will meet with my counselor to review the results which may be about 2-4 weeks after the completion of testing. At that time I will be given a copy of the report to keep. ______ Should I wish to have my report sent to another department and/or agency (e.g., Kokua), I must sign a written consent. ______ I understand that, by law, my records will be kept for 15 years before being destroyed. These records are kept securely and no one can obtain them without my written consent.
Your signature indicates that you have read the CSDC Assessment Policies and Procedures above and agreed to the items initialed.
Signature: ___________________________________ Date: __________________ Print Name: __________________________________ UHM ID# ______________ Home number: ________________________________ Date of Birth: ___________ Cell number: __________________________________ Grade: __________________
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