Dana Chidekel, PhD

​A psychological corporation

FORMS


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