Dana Chidekel, PhD

​A psychological corporation


Testing Forms

Child Assessment forms:    Child Initial History Form 

                                            Consent to test a child 9-17.pdf

Adult Assessment forms:    Adult Initial History Form

​                                            Consent to test an adult 9-17.pdf

Dependent Adult forms:     Initial History Dependent 18 + years old.pdf

                                            Consent to test a dependent adult 9-17.pdf

IEE Evaluation forms:     Child Initial History Form

​                                            Consent for testing - IEE

Other Forms and Policies


Authorization to Release Information form: Authorization to Release Information

Abridging a Report form: Abridging a Report

Request for Records of Services Provided form: Request for Medical Records

Credit Card Authorization form: Credit Card Authorization

Request for Additional Services form: Request for Additional Services

Waiver of Feedback Session form: Waiver of Feedback Session

Services Included in Fee policy: Services Included in Fee

Consent for Psychotherapy: Consent for consultation-psychotherapy.pdf

Consent to Treat a Dependent Adult: Consent to treat a dependent adult 9-17.pdf