I, name:* , agree the psychologist assigned to me through Dr. Moldover and Associates, and those assisting him/her, to perform an evaluation, including neuropsychological, psychological, and educational testing as well as report preparation and consultation with other members of the clinical team for the purpose of coordinating care.

In addition, I wish to authorize the following:*

Consultation with school personnelConsultation with lawyers /advocatesOther

If Other, Please explain:

This agreement concerns* MyselfOther

If Other, Please explain:

I understand that these services may include direct, face-to-face contact, interviewing, or testing. They may also include the psychologist’s time required for the reading of records, consultations with other psychologists and professionals, scoring of tests, interpreting the results, and any other activities to support these services. If I have questions or concerns about this assessment, the evaluator agrees to be available to discuss these after completion of the testing and interviews.

Signature of client (or parent/guardian):*

Date:*

Choose Clinician:*
Dr. MoldoverDr. HebertDr. Benetti-McQuoid