Dr. Christopher Ward

Informed Consent

In the next section, you will find the Informed Consent Form.
Please read and sign the Informed Consent Form below. Your signature will confirm that you understand and agree to the information given.
If you have any questions about the form, you can ask the doctor once the interview begins.
Once you click submit, you will be given instructions on how to start your appointment with your doctor.

To begin completing the Informed Consent, scroll down.

Informed Consent Form

ForPsych: A Forensic Psychology Practice

Informed Consent and Authorization to Release to SSA

Nature and Purpose of Evaluation

You have applied for disability benefits for you or your child. Part of this process may include a psychological evaluation. During the COVID-19 crisis, this evaluation will take place using telehealth. This means that you will video conference with the examiner via a secured platform, so your information is secure. You will be asked questions about your background and current functioning. You will also be asked questions measuring your attention, concentration, and other memory skills. A report will be prepared and then submitted to SSA. This evaluation is for examination purposes only. At no time will the examiner provide treatment or establish a doctor-patient relationship. Opportunities for Ohioans with Disabilities (SSA) is the “owner” of the report and is responsible for payment. They also control who has access to this report. ForPsych is only allowed to send a copy to OOD/SSA.

Telehealth

This service is provided by technology (including but not limited to video, phone, text, and email) and may not involve direct, face to face, communication. There are benefits and limitations to this service. You will need access to, and familiarity with, the appropriate technology to participate in the service provided. Exchange of information will not be direct, and any paperwork exchanged will likely be exchanged through electronic means or through postal delivery.

To participate, you and the examiner will need the following:

Access to a webcam or smartphone during the session.
Access to quiet, private space that is free of distractions (including cell phone or other devices) during the session.
Secure internet connection rather than public/free Wi-Fi.

At the start of the interview, you will be asked to present a picture ID. You will also be asked to provide the following information:

Name
Address of your current location
Your phone number
The name and number of an emergency contact

This information is need in case of technical issues or an emergency. If you lose connection, the examiner may call you to help fix the issues. You can call our office at 800-239-8886 X 101. If there is an emergency, the examiner may call 911 and provide responders with your information.

No one is permitted to record the evaluation.

The laws and professional standards that apply to in-person psychological services also apply to telepsychology services. This document does not replace other agreements, contracts, or documentation of informed consent.

Participation

Your participation is voluntary. ForPsych is not forcing you to participate. If you choose to participate, you are expected to be honest and try your best.

Confidentiality

Any information shared with the examiner could go in a written report that is submitted to SSA as part of your application for benefits. This means there is no confidentiality or secrets. ForPsych will send the report only to SSA. Requests for a copy of your report should be directed to that agency, as we are not allowed to release it to anyone but SSA.

Duty to Warn

Examiners are required to contact authorities if there is indication that claimants (you or your child) are actively planning to hurt themselves or others. We are also required to report suspected abuse of children, the disabled or elderly.

Risks and Benefits

Participation in the exam involves potential risks and benefits. One potential benefit is fulfilling the application requirements. The examiner may or may not agree that a psychological condition exists. You may be asked questions about very sensitive issues which may be upsetting, but they are needed for diagnostic purposes. Also, the interview may take an hour, so it may be tiring. The use of technology also has some potential risks and benefits. The ease of access to services is one possible benefit. On the other hand, your privacy may be at risk. It is strongly suggested that you use secure internet. We also suggest that you monitor your own surroundings to ensure that no one in your home hears your comments.

Recognition of Release Report

A written report will be submitted to DDD/SSA as part of your application for benefits.

Thank you for taking the time to read this document. By signing below, you indicate that you voluntarily agree to the exam via electronic service delivery means. You also acknowledge that you have read and understood all the terms and information contained herein, and you agree to the provisions in this agreement. If a minor is the client, you are signing on behalf of the minor as the authorized parent/guardian.

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