Dana Chidekel, PhD

​A psychological corporation


Testing Forms

Child Assessment forms:               Child Initial History Form 

                                                     CONSENT TO TEST A CHILD 1-19.pdf

Adult Assessment forms:               Adult Initial History Form

​                                                       CONSENT TO TEST AN ADULT 1-19.pdf

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

                                                       CONSENT TO TEST DEPENDENT ADULT 1-19.pdf

IEE Evaluation forms:                Child Initial History Form

​                                                       Consent for testing - IEE

Gifted Testing Forms                     IQ Testing History Form.pdf

                                                       Consent for IQ Testing.pdf

Other Forms and Policies


Information for the Insurance Company:Insurance reference 2019.pdf

Authorization to Release Information: Authorization to Release Information

Abridging a Report: Abridging a Report

Request for Records of Services Provided: Request for Medical Records

Credit Card Authorization: Credit Card Authorization

Request for Additional Services: Request for Additional Services

Waiver of Feedback Session: Waiver of Feedback Session

Services Included in Fee: SERVICES INCLUDED IN THE EVALAUTION FEE 1-19.pdf

Consent for Consultation-Psychotherapy: Consent for consultation-psychotherapy.pdf

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