University of Nevada, Las Vegas



STUDENT REGISTRATION FORMStudent’s Name______________________ Today’s Date __________________Birthdate ___________________________NSHE ID______________________Year in School _______________________ Major ________________________Who referred you? _______________________________________________________Reason for appointment: __________________________________________________Have you had any prior psychological assessment/testing: Yes No Don’t KnowDo you have copies of any prior assessments/IEPs/504 Plans? Yes No Don’t KnowIf so, will you be able to provide us with a copy? Yes No Address: ________________________________________________________________Phone Number: (Mobile) ________________________ May we leave a voicemail message? Yes NoPhone Number: (Home) ________________________May we leave a message on your answering machine? Yes NoMay we leave a message with another person at this phone number? Yes NoIn case of emergency, whom should we notify? Name:_____________________ Phone: _______________ Relationship: __________FOR OFFICIAL USE ONLY: Intake Appointment: Date ____________________ Time: _____________Student Case Number __________________________ Learning Specialist Program InformationGENERAL INFORMATION: These documents are intended to provide you with important information about the Academic Success Center’s (ASC) Learning Specialist Program. Please read the following documents carefully and inform the Learning Specialist if you have any questions regarding its contents before signing them. The first visit with the Learning Specialist will last between 45-60 minutes. Information regarding your educational history and other background information will be taken. (If you are under age 18, a parent or legal guardian will be required to be present at the initial appointment. A legal guardian will be required to also bring documentation of legal guardianship. The parent/legal guardian must sign this form as well as the consent, confidentiality, release, financial agreement, and notice of privacy policy forms.) Please provide any copies of previous testing that may have been performed through your school or another provider’s office. If psychological assessment/testing is recommended, the assessment/testing may be scheduled after the first appointment. The assessment/testing will be administered in the Learning Specialist’s office (or another designated ASC space) by the Learning Specialist. Assessment/testing batteries are estimated to take between four to eight hours depending on the presenting problem. The assessment/testing can be scheduled for a few hours at a time or all day depending on our scheduling and yours as well as other factors. Once the assessment/testing is completed, you will need to return to the Learning Specialist’s office to review the assessment/test results and obtain a report. If you present with issues outside of the scope of the ASC’s Learning Specialist Program, the Learning Specialist may be able to provide you with campus or community referrals.CANCELLATION/RESCHEDULING APPOINTMENTS: The ASC staff may contact you to remind you of your appointment by the telephone number you listed in the Student Registration Form. If for any reason you cannot attend your appointment, or you need to reschedule the appointment, please call the office at 702-895-3177. Please call the office at least 24 hours prior to your scheduled appointment, so we may fill the vacated slot with students, who are on the waiting list. A $10 no show fee may be charged for failure to cancel in time. Exceptions will be made if you are sick or have an emergency. If you are more than 15 minutes late for an appointment, the Learning Specialist may no longer be available to see you that day, and you may need to reschedule your appointment. If you miss or fail to cancel an appointment 2 times within a semester, you may be referred off campus for further assessment/testing services at your expense.EMERGENCIES: If you have an emergency, please go to the nearest emergency room or call 911. For psychological concerns, you may call the University of Nevada, Las Vegas’s (UNLV) Counseling and Psychological Services during office hours (Monday-Thursday 8am-6pm and Friday 9am-5pm) at 702-895-3627. After business hours, you should visit your local urgent care or emergency room or call the National Suicide Prevention Lifeline at 1-800-273-8255. If you need to call this office for questions or concerns, please call 702-895-3177 Monday-Friday between 8am-5pm excluding public holidays.I understand and agree to the above terms. I understand that I will be provided with a copy of this agreement upon request.Print name:_________________________________ Age:______ NSHE ID:________________Signature: _________________________________ Date: ______________________________ Evaluator Signature:_________________________ Date: ______________________________For Students Under 18 years old:Parent Signature: ____________________________________Date:_______________________Description of Legal Guardianship:______________________Phone number:_______________ Learning Specialist Program Information Form CONSENT FOR PSYCHOLOGICAL ASSESSMENT AND TESTINGI understand that the purpose of the first meeting is to provide information about me to the Learning Specialist to assist in the assessment/testing process. I understand that although I am expected to give honest answers, I am free to refuse to answer any questions I choose. I understand that I will be provided with an explanation of any assessment/testing procedures and their purposes. I understand that possible benefits include, but are not limited to, knowledge of my cognitive strengths and weaknesses, which may facilitate improved academic functioning/performance. There may be risks of participating in an assessment/testing. The Learning Specialist’s questions will cover personal and private matters that could cause me emotional discomfort and revive painful memories. I should inform the Learning Specialist if/when I feel discomfort. I have a right to terminate the assessment/testing at any time. If at any time during the assessment/testing I want to terminate, I will inform the Learning Specialist. I understand that the Learning Specialist may refer me to another provider. Should this occur, I understand that the Academic Success Center would not be responsible for the payment of that assessment, testing, and/or treatment. I understand that the Learning Specialist is required to notify authorities if (s)he has reason to believe that I may harm myself or others or suspects that a child or an elder person is abused. If I chose to be have psychological assessment and testing conducted by the Learning Specialist in the Academic Success Center, the information from the assessment and testing will result in a report that may provide information related to a possible diagnosis. The Learning Specialist will discuss the report with me and any others I designate by signing a release of information. I understand that the Learning Specialist may take sole possession notes during sessions regarding my psychological assessment/testing. Please note that sole possession notes are separate from a patient’s other records. Should I request a copy of my records, I understand that such a request must be made in writing. I understand that the Learning Specialist reserves the right to refuse to produce sole possession notes under certain circumstances, but may, as specifically requested or authorized by me, provide me with a summary in lieu of actual records. I understand that the Learning Specialist must keep testing documents confidential. Records will be maintained in a locked filing cabinet in a locked, private office. The Learning Specialist will be the only person with a key to the filing cabinet. Reports will be stored on an encrypted and password protected external hard drive, which will be stored in the locked file cabinet. The Learning Specialist may use testing company websites to score my assessment/testing data. These websites’ servers are located in secure data centers with encryption using Secure Socket Layer (SSL) technology in transit and at rest. Nevada Administrative Code (“NAC”) 641.219 (2) requires that records be stored “for not less than 5 years after the last date that service was rendered to the client, except that the record of a client who is a minor must be maintained for not less than 5 years after the last date that service was rendered or 1 year after the client reaches 21 years of age, whoever is longer.” NRS 629.051(7) provides “A provider of health care [includes a licensed psychologist] shall not destroy the health care records of a person who is less than 23 years of age on the date of the proposed destruction of records. The health care records or a person who has attained the age of 23 years may be destroyed in accordance with this section for those records which have been retained for at least 5 years or for any longer period provided by federal law.” The Academic Success Center will typically maintain records for five years following termination or conclusion of an assessment/testing. After five years, I understand that my records may be destroyed in accordance with applicable law and in a manner that preserves my confidentiality. If for any reason the Academic Success Center no longer employs a Learning Specialist, who is also a licensed psychologist, I understand that my records will be securely transferred, stored, and kept in a private storage facility. I understand that professional consultation is an important component of providing psychological services. As such, the Learning Specialist may participate in clinical, ethical, and legal consultation with appropriate professionals. During such consultations, I understand that the Learning Specialist will not reveal any personally identifying information regarding me or my situation without my consent. I have read fully and understand the above explanation of possible benefits and risks. I voluntarily agree to participate in the assessment/testing. I will put forth my best effort and provide truthful information to the best of my knowledge. I understand that the consent for services may be withdrawn at any time by submitting a withdrawal letter in writing addressed to the Learning Specialist.I have read the above terms and understand and agree to those terms. I understand that I will be provided with a copy of this agreement upon request.Print name:_________________________________ Age:______ NSHE ID:________________Signature: _________________________________ Date: ______________________________ Evaluator Signature:_________________________ Date: ______________________________Consent for Psychological Assessment and Testing FormFor Students Under 18 years old:Parent Signature: ____________________________________Date:_______________________Description of Legal Guardianship:______________________Phone number:_______________ Consent for Psychological Assessment and Testing Form LIMITS OF CONFIDENTIALITYThe information you disclose is generally confidential. Your assessment/testing results will not appear in any academic records or transcripts. No information is released to your parents (unless you are under age 18), faculty members, or outside agencies without your prior written consent. There are a few exceptions to confidentiality outside of your academic information under emergency and legal circumstances:If you are at risk of harming yourself or another person, it is the Learning Specialist’s duty to warm your family, an intended victim, or the authorities (e.g., police) of the risk in order to prevent harm to you or another person.If the Learning Specialist suspects child abuse or elder abuse, it is also the Learning Specialist’s duty to report the suspicions to Child Protective Services or Elder Protective Services. If you become involved in a court case or legal proceeding, disclosure may be required in response to a court order and/or subpoena. If possible, the Learning Specialist will not inform the aforementioned parties without first sharing the intention with you. However, in some cases, it may not be possible for the Learning to inform you of the disclosure permitted pursuant to one of the above listed exceptions. Privileged communication is a legal term for a right that belongs to you to restrict the Learning Specialist, who is a licensed psychologist, from disclosing confidential communications. However, the Learning Specialist/Licensed Psychologist may be required to disclose confidential communications under certain exceptions, including but not limited to disclosure required by state or federal law (NRS 41.207). You should discuss any concerns you may have regarding psychologist-patient privilege with your attorney. Should you need a copy of your records sent to someone else, or should someone else request us to do so, you must sign a release form stating that you give the Learning Specialist permission to release a copy of your records. I have read the above and understand the legal responsibility of the Learning Specialist and give permission for the Learning Specialist to make such decisions to disclose my information when necessary as permitted by applicable laws. I understand that I will be provided with a copy of this agreement upon request.Print name:_________________________________ Age:______ NSHE ID:________________Signature: _________________________________ Date: ______________________________ Evaluator Signature:_________________________ Date: ______________________________For Students Under 18 years old:Parent Signature: ____________________________________Date:_______________________Description of Legal Guardianship:______________________Phone number:_______________ Limits of Confidentiality FormCONSENT FOR RELEASE OF CONFIDENTIAL INFORMATIONI, ____________________, hereby authorize Jenya Gaskin, Psy.D., permission to…____ Speak to the person(s)/organization listed below____ Release my records to the person(s)/organization listed below____ Request records from the person(s)/organization listed below____ Other: _________________________________________Name:___________________________________________________________________________________ Contact information:_______________________________________________________________________Name: ___________________________________________________________________________________ Contact information:________________________________________________________________________Name:___________________________________________________________________________________ Contact information:_______________________________________________________________________ Purpose of release: __________________________________________________________________________________________________________________________________________________________________________________________________________________________Specify any limitations: ______________________________________________________________________________________________________________________________________Releasing my information to others (e.g., primary care physician, parents, etc.) may help coordinate services or care for my benefit. I understand that I am not required to permit the Learning Specialist to release my information to anyone in order to be assessed by the Academic Success Center’s Learning Specialist Program. I understand that my records are protected under applicable federal and state laws. My records cannot be disclosed without my written consent unless otherwise provided for by federal and state laws. I understand that this authorization for release of records is effective immediately, and I may revoke this written authorization at any time by informing the above named parties in writing. That written letter needs to be received by the Academic Success Center office for it to be effective. However, the written revocation will have no effect on actions taken prior to the revocation. The University and its officers and/or employees are hereby released from any liability for disclosure of the above information to the extent indicated and authorized herein. This written authorization will expire after one year.I have read, understand, and agree to the above conditions. I understand that I will be provided with a copy of this written authorization upon request.Print name:_________________________________ Age:______Date of Birth:______________Signature: _________________________________ Date: ______________________________ Evaluator Signature:_________________________ Date: ______________________________For Students Under 18 years old:Parent Signature: ____________________________________Date:_______________________Description of Legal Guardianship:______________________Phone number:_______________ Consent for Release of Confidential Information Form FINANCIAL AGREEMENTI understand that a fee may be charged for the assessment/testing based on my financial aid status. I understand that I may be asked to provide documentation of my financial aid status if the Learning Specialist cannot access this information through MyUNLV. I understand and acknowledge that payment will be due immediately following the initial meeting, if an assessment is recommended, or service will not be rendered. The fee for the full assessment/testing with the Academic Success Center’s Learning Specialist Program will be a one-time payment on a sliding scale. I acknowledge and understand that health insurance plans will not be accepted to pay for services at this time. I understand that if I am referred to another provider or decide to be assessed outside of the Academic Success Center’s Learning Specialist Program, the Academic Success Center is not responsible for care or charges incurred at other offices. Payment methods include major credit and debit cards only.I have read, fully understand, and agree to the Academic Success Center’s Financial Agreement. I understand that I will be provided with a copy of this Financial Agreement upon request.Print name:_________________________________ Age:______ NSHE ID:________________Signature: _________________________________ Date: ______________________________ Evaluator Signature:_________________________ Date: ______________________________For Students Under 18 years old:Parent Signature: ____________________________________Date:_______________________Description of Legal Guardianship:______________________Phone number:_______________ Learning Specialist Program Notice of Privacy Policies Your Information. Your Rights. Our Responsibilities.This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.Your RightsYou have the right to: Get a copy of your paper or electronic health recordAmend your paper or electronic health recordRequest confidential communicationAsk us to limit the information we shareGet a list of those with whom we have shared your informationGet a copy of this privacy noticeChoose someone to act for youFile a complaint if you believe your privacy rights have been violatedYour ChoicesYou have some choices in the way that we use and share information as we: Tell family and friends about your conditionProvide psychological evaluationsMarket our services and sell your informationRaise funds Our Uses and DisclosuresWe may use and share your information as we: Treat youRun our organizationBill for your servicesHelp with public health and safety issuesDo researchComply with the lawWork with a medical examiner or funeral directorAddress workers’ compensation, law enforcement, and other government requestsRespond to lawsuits and legal actionsYour RightsWhen it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.Get an electronic or paper copy of your health record You can ask to see or get an electronic or paper copy of your health record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.Ask us to correct your medical recordYou can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.We may say “no” to your request, but we will tell you why in writing within 60 days.Request confidential communicationsYou can ask us to contact you in a specific way (for example, home or cell phone) or to send mail to a different address. We will say “yes” to all reasonable requests.Ask us to limit what we use or shareYou can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.Get a list of those with whom we’ve shared informationYou can ask for a list (accounting) of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why.We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 monthsGet a copy of this privacy noticeYou can ask for a paper copy of this notice at any time. We will provide you with a paper copy promptly.Choose someone to act for youIf you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.We will make sure the person has this authority and can act for you before we take any action.File a complaint if you feel your rights are violatedYou can complain if you feel we have violated your rights by calling Dr. Jenya Gaskin at (702) 895-3177 or by writing to 4505 S. Maryland Parkway, Box 452001, Las Vegas, NV 89154-2001. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting ocr/privacy/hipaa/complaints/.We will not retaliate against you for filing a complaint.Notification of breachYou have a right to be notified upon a breach of any of your unsecured protected health information.Your ChoicesFor certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.In these cases, you have both the right and choice to tell us to:Share information with your family, close friends, or others involved in your careShare information in a disaster relief situationIf you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.In these cases we never share your information unless you give us written permission:Marketing purposesSale of your informationMost sharing of psychotherapy notesIn the case of fundraising:We may contact you for fundraising efforts, but you can tell us not to contact you again.Our Uses and DisclosuresHow do we typically use or share your health information? We typically use or share your health information in the following ways.Treat youWe can use your health information and share it with other professionals who are treating you.Example: A doctor treating you for an injury asks another doctor about your overall health condition.Run our organizationWe can use and share your health information to run our practice, improve your care, and contact you when necessary.Example: We use health information about you to manage your treatment and services. Bill for your servicesWe can use and share your health information to bill and get payment from health plans or other entities. Example: We could give information about you to your health insurance plan so it will pay for your services. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: ocr/privacy/hipaa/understanding/consumers/index.html.Help with public health and safety issuesWe can share health information about you for certain situations such as: Preventing diseaseHelping with product recallsReporting adverse reactions to medicationsReporting suspected abuse, neglect, or domestic violencePreventing or reducing a serious threat to anyone’s health or safetyDo researchWe can use or share your information for health research under certain ply with the lawWe will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.Respond to organ and tissue donation requestsWe can share health information about you with organ procurement organizations.Work with a medical examiner or funeral directorWe can share health information with a coroner, medical examiner, or funeral director when an individual dies.Address workers’ compensation, law enforcement, and other government requestsWe can use or share health information about you:For workers’ compensation claimsFor law enforcement purposes or with a law enforcement officialWith health oversight agencies for activities authorized by lawFor special government functions such as military, national security, and presidential protective servicesRespond to lawsuits and legal actionsWe can share health information about you in response to a court or administrative order, or in response to a subpoena. Our ResponsibilitiesWe are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: ocr/privacy/hipaa/understanding/consumers/noticepp.html.Changes to the Terms of this NoticeWe can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request in our office and/or on our web site.Effective Date of this Notice is January 01, 2015This Notice of Privacy Practices applies to the UNLV Academic Success Center’s Learning Specialist Program.By signing this form, I acknowledge that I have received this Notice of Privacy Practices with an effective date of January 01, 2015. Print name:_________________________________ Age:______ NSHE ID:________________Signature: _________________________________ Date: ______________________________ Evaluator Signature:_________________________ Date: ______________________________For Students Under 18 years old:Parent Signature: ____________________________________Date:_______________________Description of Legal Guardianship:______________________Phone number:_______________ University of Nevada, Las Vegas4505 S. Maryland ParkwayLas Vegas, NV 89154-3020(702) 895-3177 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download