Client Intake – GoodmanHealth

Section 1: Participant/Parent Information

Please provide the primary contact information for the parent or legal guardian.

Full Name *

Email Address *

Phone Number *

Section 2: Custody/Relationship Information

Information regarding legal relationship and custody status.

Relationship to Client *

Custody Type *

Section 3: Assessment Purpose

Acknowledgment of the clinical nature of this assessment.

I understand that:

This assessment is for clinical purposes and not for forensic or legal testimony.

Acknowledgment of Purpose *

I understand that this assessment is for clinical purposes and not for forensic or legal testimony.

Section 4: Remote Services

Consent for services delivered via telehealth.

I understand that:

Services are provided via secure psychological assessment application.
I have the right to withdraw consent for psychological assessment at any time.

Consent for Remote Services *

I consent to receiving psychological services via secure video conferencing.

Section 5: Testing Conditions

Ensuring the integrity of the remote testing environment.

Testing conditions are essential for accuracy:

The environment must be quiet and free from distractions.
No outside assistance or resources may be used during testing.
Recording of testing sessions is strictly prohibited.
A stable internet connection and functional camera/microphone are required.

Testing Conditions Acknowledgment *

I agree to maintain the required testing conditions as outlined by the provider.

Section 6: Telehealth Risks

Understanding potential limitations of remote services.

I understand these limitations:

Technical failures may interrupt or delay the session.
Privacy cannot be guaranteed if the client's environment is not secure.
Remote assessment may lack some nuances of in-person interaction.
Emergency response may be delayed due to physical distance.

Risk Acknowledgment *

I understand the risks associated with telehealth, including technical failures and privacy limitations.

Section 7: Confidentiality & Mandated Reporting

Legal and ethical boundaries of privacy.

I understand that:

Information obtained is confidential and protected by applicable state and federal law.
Records are stored electronically using secure systems.
Information may be released only with written authorization or as required by law.
The clinician is a mandated reporter and must report suspected child abuse or neglect.
Disclosure may occur if there is risk of serious harm to the minor or others.

Confidentiality Acknowledgment *

I understand that my information is confidential except where disclosure is required by law.

Mandated Reporting Acknowledgment *

I understand the provider's duty to report suspected abuse or neglect.

Section 8: Guardian Authorization & Minor Participation

Specific considerations for the assessment of a minor.

I understand and agree to the following:

I will provide oversight during the remote session to ensure the minor remains focused and follows instructions.
The minor's role is to participate to the best of their ability without external coaching or assistance.
Results and clinical recommendations will be communicated to the legal guardian(s) through a formal feedback session.
While I have a right to information, the clinician may maintain certain confidentiality boundaries with the minor to foster a therapeutic assessment environment.

Guardian Oversight *

I agree to provide necessary oversight during the remote assessment session.

Minor Participant Role *

I understand the minor's role and will ensure no external assistance is provided.

Confidentiality Boundaries *

I understand the clinician may maintain certain confidentiality boundaries with the minor.

Section 9: Electronic Signature

Finalizing your authorization.

I agree that:

My typed name below constitutes my legal signature.
This electronic signature has the same legal effect as a handwritten one.
I have read and understood all sections of this authorization form.

Electronic Signature Agreement *

I agree that my typed name below serves as my legal electronic signature.

Full Legal Name *

Date

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Please complete all required fields and acknowledgments to submit.

Client Intake Authorization

Section 1: Participant/Parent Information

Section 2: Custody/Relationship Information

Section 3: Assessment Purpose

Section 4: Remote Services

Section 5: Testing Conditions

Section 6: Telehealth Risks

Section 7: Confidentiality & Mandated Reporting

Section 8: Guardian Authorization & Minor Participation

Section 9: Electronic Signature

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