Working Agreement for Dr. Kelsey Lisle, PsyD, Bay Kids FL
By scheduling an appointment with Bay Kids FL (Dr. Kelsey Lisle) you are agreeing to the following.
I provide neuropsychological assessments. The neuropsychological evaluations I provide consist of tests to further assess one's cognitive capacities, academic skills, attention and executive functioning, and social-emotional functioning.
Payment For Assessment Services:
Legal/Custody Case Involvement: I do not participate in any form of legal or custody proceedings of any kind. I will not appear in court or make any determinations/suggestions regarding the custody of your child. I do not evaluate a parent’s fitness for parenting or make any suggestions/recommendations regarding custody agreements. I do not collaborate with Guardian Ad Litems; however, following the evaluation the parents may share the report with the Guardian. By making an appointment for an evaluation or therapy, you are agreeing to these terms.
After Hours & Emergency Contact: Should you need to reach me during or after business hours you may leave a message on my voicemail or e-mail me. Please be aware that I do not provide emergency care. Should you need such services, during and/or after business hours, you should call 911. Please be aware that a secure and confidential correspondence cannot be guaranteed when communicating via e-mail.
Confidentiality & Records: All verbal communications between you and I are confidential and may not be disclosed to anyone without your written authorization. However, there are some situations in which disclosure is permitted or required by law, without your consent or authorization:
If such a situation arises, I will make every effort to fully discuss it with you before taking any action. Disclosure will be limited to what is necessary for each situation.
Records: I keep Protected Health Information in your child’s and your clinical records. You may examine and/or receive a copy of these records, if you request it in writing, except when: (1) the disclosure would physically or psychologically endanger you, the child, and/or others who may or may not be referenced in the records, and/or (2) the disclosure includes confidential information supplied by others.
Comprehensive Report: This document will serve as permission allowing me to e-mail you a copy of the report unless you request a paper copy. Remember e-mail is not a secure way to transmit confidential information.
By making a testing/therapy appointment with this provider you are agreeing to the above working agreement.
By scheduling an appointment with Bay Kids FL (Dr. Kelsey Lisle) you are agreeing to the following.
I provide neuropsychological assessments. The neuropsychological evaluations I provide consist of tests to further assess one's cognitive capacities, academic skills, attention and executive functioning, and social-emotional functioning.
- The number of sessions required for conducting the assessment is typically two, depending upon the nature and number of tests administered. The duration and frequency are flexible and based on your child’s needs and to get the best diagnostic picture. Assessment sessions range from 60 to 120 minutes in duration and usually are completed in two sessions. I tell parents to budget 2 hours per testing session unless noted otherwise.
- Following the testing sessions, you will be scheduled to have a feedback session to discuss the results of testing, as well as any questions or concerns you may have. At that feedback session, you will receive recommendations including related services that may be beneficial for your child.
- The written report will be generated within two to three weeks following the feedback session.
- The report is sent via email in a PDF format. The report will not be password protected, unless requested. If there is an issue with this method, let the examiner know prior to the feedback session. Please be aware that a secure and confidential correspondence cannot be guaranteed when communicating via e-mail.
Payment For Assessment Services:
- Payment is required at the first testing session.
- Feedback from the testing, as well as a written report will be provided after payment has been made in full.
- Fees for psychological testing cover: test administration, review of records, scoring and interpretation, oral feedback of test results, reasonable consented third party-communication, and a comprehensive written test report. Any additional services requested will be billed separately based on a prorated hourly rate.
- Insurance is not accepted/nor do I engage in any communication with any insurance company. If a superbill/receipt is desired, please let the examiner know and it will be sent to you via email.
- Payment for therapy sessions or additional feedback sessions are due at the time of each treatment/meeting.
Legal/Custody Case Involvement: I do not participate in any form of legal or custody proceedings of any kind. I will not appear in court or make any determinations/suggestions regarding the custody of your child. I do not evaluate a parent’s fitness for parenting or make any suggestions/recommendations regarding custody agreements. I do not collaborate with Guardian Ad Litems; however, following the evaluation the parents may share the report with the Guardian. By making an appointment for an evaluation or therapy, you are agreeing to these terms.
After Hours & Emergency Contact: Should you need to reach me during or after business hours you may leave a message on my voicemail or e-mail me. Please be aware that I do not provide emergency care. Should you need such services, during and/or after business hours, you should call 911. Please be aware that a secure and confidential correspondence cannot be guaranteed when communicating via e-mail.
Confidentiality & Records: All verbal communications between you and I are confidential and may not be disclosed to anyone without your written authorization. However, there are some situations in which disclosure is permitted or required by law, without your consent or authorization:
- I may consult with other mental health professionals regarding your child’s or your case. However, every effort is made to avoid revealing identity during such activities.
- If the situation involves a serious threat of physical violence against an identifiable victim, I must take protective action, including notifying the potential victim and contacting the police.
- If I suspect the situation presents a substantial risk of physical harm to you, your child, others, or property then hospitalization may be needed, or I may contact family members or others who can help.
- If I suspect that a child under the age of 18, an elder, or a dependent adult has been a victim of abuse or neglect, the law requires that I file a report with the appropriate protective and/or law enforcement agency.
- If you are involved in a court proceeding and a request is made for information about the services provided to your child, I cannot provide any information, including release of clinical records, without your written authorization, a court order, or a subpoena.
- If you file a complaint or lawsuit against me, disclosure of relevant information may be necessary as part of a defense strategy.
- If a government agency is requesting the information pursuant to their legal authority (e.g., for health oversight activities), I may be required to provide it for them.
If such a situation arises, I will make every effort to fully discuss it with you before taking any action. Disclosure will be limited to what is necessary for each situation.
Records: I keep Protected Health Information in your child’s and your clinical records. You may examine and/or receive a copy of these records, if you request it in writing, except when: (1) the disclosure would physically or psychologically endanger you, the child, and/or others who may or may not be referenced in the records, and/or (2) the disclosure includes confidential information supplied by others.
Comprehensive Report: This document will serve as permission allowing me to e-mail you a copy of the report unless you request a paper copy. Remember e-mail is not a secure way to transmit confidential information.
By making a testing/therapy appointment with this provider you are agreeing to the above working agreement.