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Informed Consent for Forensic Evaluation

 
Welcome to Ray S. Kim, Ph.D. and Associates, Inc. This document is an Informed Consent for Forensic Evaluation and contains important information about our professional and business policies. It also contains summary information about three areas: 1) Health Insurance Portability and Accountability Act (“HIPAA”), a federal law that provides privacy protections and patient rights about the use and disclosure of the patient’s Protected Health Information (“PHI”) for the purposes of treatment; 2) the Illinois Mental Health and Developmental Disabilities Confidentiality Act (“IMHDDCA”), a state law that provides privacy protections for a patient’s mental health records and communications, and 3) information about our practice’s health care operations and payment. Although this document is lengthy, it is very important that you read through
and understand it.


General Information

 

The mission of Ray S. Kim, Ph.D. and Associates, Inc. is to deliver psychological services to you and to assist the court system. We conduct forensic evaluations in order to enhance judicial fairness and foster a more informed legal process. You have been referred to Ray S. Kim, Ph.D. and Associates, Inc. in order to make some decisions about your legal situation. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This Informed Consent for Forensic Evaluation will provide a clear framework for our work together. Please feel free to discuss any of the contents of this Informed Consent for Forensic Evaluation with your provider prior to your signing below, or at any time in the future. By signing this document, you are consenting to participate in a forensic evaluation with Ray S. Kim, Ph.D. and Associates, Inc. Please be aware that Ray S. Kim, Ph.D. and Associates does not provide psychotherapy services to the individuals for whom a forensic evaluation has been conducted.


Ray S. Kim, Ph.D. and Associates, Inc. conducts a variety of forensic evaluations, including, but not limited to, psychological evaluations, alcohol and substance use evaluations, violence risk assessments, sex offender risk assessments, pre-trial and pre-sentence evaluations, fitness evaluations, competency evaluations, discretionary transfer evaluations, mitigation assessments, clemency evaluations, FOID appeal evaluations, custody evaluations, pre-employment assessments, fitness for duty evaluations, workers’ compensation, disability determinations, and personal or occupational injury evaluations.


You may revoke this Informed Consent for Forensic Evaluation in writing at any time. Such a revocation will be binding other than for any action(s) Ray S. Kim, Ph.D. and Associates, Inc. has taken in reliance on it (e.g., if there are outstanding obligations to process or substantiate claims made under your policy or if you have not satisfied any financial obligations to Ray S. Kim, Ph.D. and Associates, Inc. that you have incurred). Please read and indicate that you have reviewed this Informed Consent for Forensic Evaluation and agree to it by signing and dating at the end of this document.


Forensic Evaluation

 

The forensic evaluation is conducted at the request of a third party. Therefore, it is somewhat different than other, more traditional mental health services. It is important for you to understand how a forensic evaluation differs from a more traditional psychological evaluation. While the results of this forensic evaluation may or may not be helpful to you personally, the goal of the forensic evaluation is to provide information about how you are functioning psychologically to the individual, agency, or court requesting the forensic evaluation. In most cases, the forensic evaluation is intended to be used in some type of legal proceeding. As such, the confidentiality of the forensic evaluation and the results of it are determined by the rules and applicable laws of that legal system. Pursuant to Section 10(a)(4) of the Illinois Mental Health and Developmental Disabilities Confidentiality Act, records and communications made, created, and/or maintained in the course of a court ordered forensic evaluation are not considered to be confidential or privileged and may be admissible as to issues involving your physical or mental condition so long as they are germane to the legal proceedings and you are a party to said proceedings.


Once a decision has been made to use the forensic evaluation in a legal proceeding, the evaluation and any information pertaining to it will likely be admissible into evidence as well as any other information that was provided concerning your mental health and functioning. If you have any concerns about the use or distribution of the evaluation, you should discuss these issues carefully with your attorney. If someone other than your attorney requested the forensic evaluation, that individual may be deemed to have complete authority over the results, including whether or not any information will be released to you or to anyone else. In addition, because the forensic evaluation was requested by another party, and is not for the purpose of treatment or counseling, the confidentiality of the forensic evaluation may have fewer legal protections. Ray S. Kim, Ph.D. and Associates, Inc. will not release the information unless instructed to do so by the person or entity that hired Ray S. Kim, Ph.D. and Associates, Inc. or when we are legally required to do so.


Your participation in the forensic evaluation is voluntary. We will not conduct the forensic evaluation without your signature on this document. You have the right to stop the forensic evaluation at any time. There may be legal consequences if you stop the evaluation. Therefore, it is in your best interest to consult with an attorney before doing so. In addition, if appointments are not kept or are canceled within 24 hours of the appointment time, the person or entity requesting the forensic evaluation will incur charges for the unused time that has been set aside for these services. The forensic evaluation itself consists of two parts – an oral interview with the evaluator and psychological testing. In addition, it may be necessary for Ray S. Kim, Ph.D. and Associates, Inc. to review other related materials such as court records, depositions, transcripts, medical records, mental health records, other relevant documents, etc. If you have a question about any aspect of this forensic evaluation at any time, please ask your evaluator. In addition, if you need a break from the forensic evaluation, please let your evaluator know and we will stop. Once the forensic evaluation has been completed, and with the permission of the requesting party, your evaluator may be able to have a meeting with you to explain the results and answer any questions you may have. Additionally, the evaluator may be asked to testify in a legal proceeding and may be asked about anything you have told the evaluator during the process of the forensic evaluation.


Fees, Cancelation Policy, and Changes

 

The fees of Ray S. Kim, Ph.D. and Associates, Inc. are usual and customary for the services provided to its clients. Your clear understanding of the financial and practice policies is important to our professional relationship. Please discuss the fees with your evaluator should you have any questions.


Your signature below acknowledges that you have given Ray S. Kim, Ph.D. and Associates, Inc. permission to charge any credit card you provide and grant permission for Ray S. Kim, Ph.D. and Associates, Inc. to receive payments via Square, Zelle, or another form of electronic payment.


You will be charged for all time spent on your behalf, the evaluator’s time spent preparing reports, reading letters and consultations, travel time for “out of office” services (including, but not limited to, depositions and/or court appearances), and telephone calls that are longer than 10 minutes in length (e.g., with the client, a family member, or with other professionals including, but not limited to, attorneys, judges, therapists, psychologists, school personnel, doctors, and psychiatrists).


Please remember to cancel or reschedule 24 hours in advance if you need to do so. This is necessary because a time commitment is made to you and is held exclusively for you. If you need to cancel or reschedule an appointment, please call 847-309-7475. If cancelation is less than 24 hours prior to your appointment, you will be responsible for the missed appointment at the rate of $200.00 before further services are rendered. 


A $10.00 service charge will be charged for any checks returned for any reason.


Insurance

 

Ray S. Kim, Ph.D. and Associates, Inc. is not in network for any insurance carriers. A statement of services to be submitted to insurance for reimbursement can be provided when requested. You authorize the use and disclosure of your personal health information for the purposes of diagnosing or providing an evaluation to you or for the purposes of conducting the healthcare operations. You authorize Ray S. Kim, Ph.D. and Associates, Inc. to release any information required in the process of applications for financial coverage for the services rendered. This authorization provides that Ray S. Kim, Ph.D. and Associates, Inc. may release objective information related to your diagnosis and treatment, which may be requested by your insurance company or its designated agent. This section does not provide consent for the release of your mental health records. Additional specific consent must be obtained for that purpose.


Emergencies

 

Ray S. Kim, Ph.D. and Associates, Inc. is not equipped to handle mental health emergencies. If you are in crisis, especially if you are seriously considering harming yourself or someone else, call 911. If you need to speak with someone immediately, go to your nearest emergency room or call 911.


Electronic Communication

 

Ray S. Kim, Ph.D. and Associates, Inc. cannot ensure the confidentiality of any form of communication through electronic media, including e-mail and text messages. Standard texting is not secure and anything that is written may be seen by unauthorized third parties. You understand that Ray S. Kim, Ph.D. and Associates, Inc. recommends encrypted forms of communication. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancelations, Ray S. Kim, Ph.D. and Associates, Inc. will do so. Ray S. Kim, Ph.D. and Associates, Inc. cannot guarantee an immediate response via text message or e-mail.


Social Media and Telecommunication

 

Due to the importance of your confidentiality and the importance of minimizing dual relationships, Ray S. Kim, Ph.D. and Associates, Inc. does not accept friend or contact requests from current or former clients for whom a forensic evaluation has been conducted on any social networking site (e.g., Facebook, Instagram, LinkedIn, etc.) personally or professionally. You are welcome to follow the practice on social media, but comments are not advised. Should you post any comment on Ray S. Kim, Ph.D. and Associates, Inc.’s social media pages, please be aware that Ray S. Kim, Ph.D. and Associates, Inc. will not interact or otherwise engage with you on any social media page. We believe that adding clients or interacting as “friends” or “contacts” on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our professional relationship. If you have questions about this, please bring them up for more conversation.


Telehealth

 

Ray S. Kim, Ph.D. and Associates, Inc. and you may decide to engage in telehealth sessions to conduct a portion of or all of the forensic evaluation rather than an in-person evaluation when appropriate. Your evaluator and you will discuss whether telehealth is an appropriate format for you. Telehealth means the delivery of mental health services, including evaluations, to a client, regardless of the client’s location so long as the client is within a PSYPACT participating state, provided by way of an interactive telecommunication system. Please note that the system that Ray S. Kim, Ph.D. and Associates, Inc. uses is Doxy.me, which is compliant with HIPAA. Ray S. Kim, Ph.D. is a member of PSYPACT and is able to provide telepsychological services to clients whose state of residence has enacted PSYPACT legislation.


If you and your evaluator chose to utilize telehealth for some or all of your evaluation, you need to understand the following: (1) You retain the option to withhold or withdraw consent for telehealth at any time without affecting the right to future in-person evaluation or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. (3) Your access to all mental health records created during a telehealth session are the same as mental health records created during an in-person evaluation and copies are available upon request to the extent permitted by law. (4) There are potential risks, consequences, and benefits of telehealth sessions. Potential benefits include, but are not limited to, improved communication capabilities, consultations, support, better continuity of care, and reduction of lost work time and travel costs. An in-person evaluation has benefits as the evaluator may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using technology in therapy services, potential risks include, but are not limited to, the evaluator’s inability to make visual and olfactory observations of potentially clinically or therapeutically relevant issues such as your physical condition, including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerisms or gestures, physical or medical conditions, including bruises or injuries, basic grooming and hygiene habits, including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, gender, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or body expression. Potential consequences, thus, include the fact the evaluator may not be aware of what your evaluator may consider to be important information, including information that you may not recognize as significant to present verbally to the evaluator.


By agreeing to participate in telehealth sessions, you consent to the following:​

 

  • You understand that your evaluator and you have agreed to your evaluation session(s) to proceed as telehealth.

  • Your evaluator will explain to you how the video conferencing technology that will be used for a telehealth session will not be the same as an in-person visit due to the fact that you will not be in the same room as the evaluator.

  • You understand that a telehealth session has potential benefits, including easier access to care and the convenience of meeting from a location of your choosing. You understand that the location must be located within a member state of PSYPACT.

  • You understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. You understand that your evaluator or you can discontinue the telehealth session if it is felt that the videoconferencing connections are not adequate for the situation.

  • You have had a direct conversation with your evaluator during which you had the opportunity to ask questions in regard to this procedure. Your questions have been answered, and the risks, benefits, and any practical alternatives have been discussed with you in a language in which you understand.

  • Telehealth is NOT an Emergency Service, and in the event of an emergency, you will use a phone to call 911.

  • To maintain confidentiality, you will not share your telehealth appointment link with anyone unauthorized to attend the appointment.

OUR CONTACT INFORMATION:

2300 Barrington Road, Suite 400

Hoffman Estates, Illinois 60169

PRIVACY OFFICER:

Ray S. Kim, Ph.D.

Office: 847-309-7475

Fax: 847-984-9292

E-mail: drkim@raykimassociates.com

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