Please complete and bring these forms to your first testing appointment
- Developmental History Questionnaire form. PDF DOC
- Assessment Consent form. PDF
- Confidential Authorization To Release Information. You should complete one release for each person you would like me to talk to about your child. PDF
- Email Agreement regarding email preferences. PDF Make sure to circle ‘yes’ or ‘no’ to indicate specific information you would or would not like me to include in any emails.
- Read about Your Rights to Privacy under HIPAA PDF DOC
- Acknowledgement of Receipt of Dr. Kristen Herzel’s Notice of Privacy Practices to indicate that you understand your rights under HIPAA rights. PDF
If your child is 14 years old or older, s/he will be asked to sign all of the above forms, as well.
Please collect and bring these records, or email them to me at firstname.lastname@example.org prior to our first appointment:
- Current IEP or Section 504 Service Agreement
- Previous evaluations from the school district, early intervention, medical providers, or other psychologists
- Standardized test results
- Any medical visit letters from your developmental pediatrician, psychiatrist or neurologist
I prefer to receive records electronically, via email, dropbox and/or flash drive. However, where this is not possible, I will borrow copies of your paper records and return them after I’ve written the report.
SCHOOL VISIT (if applicable):
- Please introduce me to your child’s teacher or case manager via e-mail.
- Sign a permission with the school district.
- Complete an Confidential Authorization to Release Information form (PDF, discussed above) for the school. Circle “obtain from,” which means I will get information from the school but will not share any information with them.
- Provide me with names and phone numbers for teacher and principal.
- Let me know if you have any preference for what time of day I visit or what activities I observe.
- When I have the visit scheduled, please put that on your calendar in case you need to reach me if your child is sick or otherwise not in school.
- On the day of the scheduled observation, please text me at 610-541-0710 if it turns out that your child will be absent.