Documents & Forms

By pushing submit, I state that I have read the above form and provided my signature as agreement to the terms and conditions included.

I hereby assign benefits payable for the eligible claims to the Provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to the Provider. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the Provider for any services rendered and/ or supplies provided.

I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this Assignment, that any benefit payment made in accordance with this Assignment will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment.

I understand that this Assignment will apply to all eligible claims submitted electronically by the Provider and that I may revoke it at any time by providing written notice to the insurer/plan administrator.

If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the Provider.

By pushing submit, I state that I have read the above form and provided my signature as agreement to the terms and conditions included.

Consent to Collect and Exchange Personal Information

Message to the Plan member, Spouse and/or Dependent regarding Personal Information

Personal information that we collect and disclose about you, and if applicable, your spouse and/or dependents, is used by the insurer and/or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administering the group benefits plan, including the investigation of fraud and / or plan abuse.

Authorization and Consent

I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes.

I authorize the insurer and / or plan administrator and their service provider(s) to: use my personal information for the above purposes.

exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits or other benefits programs when relevant for the above purposes.

exchange personal information concerning any claims submitted with the plan member or a person acting on behalf of the plan member.

exchange personal information for the above purposes electronically or in any other manner.

I understand that personal information may be subject to disclosure to those authorized under applicable law.

I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of the group benefits plan.

Additional Consent Applicable to Plan Members Only

I confirm that I am authorized by my spouse and/or dependents, if any, to disclose personal information about them to the insurer and/or plan administrator and their service provider(s) for the purposes described above and I confirm that my spouse and/or dependents also authorize the insurer and/or plan administrator and their service provider(s) to disclose information about their claims to me, for the purposes of assessing and paying a benefit, if any, and managing the group benefits plan. I also authorize my spouse and/or dependents to assign benefit payments under the plan to the healthcare provider.

In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning claims submitted, I acknowledge and agree that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant organization including law enforcement bodies, regulatory bodies, government organizations, medical suppliers and other insurers, and where applicable my Plan Sponsor, for the purposes of investigation and prevention of fraud and/or plan abuse.

If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where applicable, my Plan Sponsor, for that purpose.

By pushing submit, I state that I have read the above form and provided my signature as agreement to the terms and conditions included.

(print your name)

give consent to Sarra Ng, Registered Psychologist # 5445 at Sharon Blott Psychological Services, to provide Assessment Services to:

Westmount Charter School | Gifted and Talented Education (GATE)

ADHD/Learning Disability/Intellectual Disability

PDD, AISH, Disability Tax Credit, Capacity Assessment

About Your Psychologist

Sarra is a Registered Psychologist with a Masters of Education in School and Applied Psychology. She completed her training at the Calgary Board of Education, allowing her to specialize in psycho-educational assessments for children, adolescents, and adults. Sarra has over 8 years of experience supporting individuals with Autism Spectrum Disorder, learning disabilities, ADHD, and developmental delays within multiple settings and programs. Her core values include integrity, honouring diversity, and professionalism. Using a strength-based approach, her mission is to help empower individuals to bridge the gap, reach their potential, and succeed.

I Acknowledge and Consent to the Following:

Assessment

The assessment will involve the administration of standardized assessment measures as discussed in the intake interview. This typically includes a measure of intelligence (WPPSI-IV, WISC-V, WAIS-IV), achievement (WIAT- III), checklists for ADHD and executive functioning, as well as online and/or computer measures. The types of assessment measures completed will depend on the nature of the referral. The process of assessment is discussed during the intake meeting. Specialized assessment measures are administered for the assessment of Autism including the ADI-R and ADOS-II.

Please note that as per College of Alberta Psychologist guidelines, raw scores, and other such reports as produced by Pearson Clinical Assessments cannot be released directly to parents. Instead, all clinical information is interpreted by the psychologist and written into a comprehensive report.

Fees

Fees are billed in accordance with the current fee schedule as set forth by the Psychologists Association of Alberta. Fees are discussed during the initial consult and intake to ensure that clients are aware of the total cost of assessment. A flat rate is charged for all assessments to ensure transparency in all financial matters. An invoice will be provided for reimbursement. Effective April 1st, 2018, the fee is $200.00 per hour. Fees are as follows:

$500.00 initial fee | $900.00 if gifted (Westmount Charter School) | $1,500.00 if gifted (GATE)

$2,200.00

$1,000.00

$700.00

$2,600.00 (Includes Psychoeducational Assessment)

A 30-minute fee ($100.00) is charged for no-show or late cancellation appointments.

Payment

The client and/or parents are responsible for fulfilling their financial obligation for the assessment. Payment is billed at the end of each session with an invoice provided for insurance reimbursement. The final balance owing is due at the last appointment in which a report is presented to the parents and/or client. All questions about billing should be directed to Sharon Blott.

Depending on your insurance provider, direct billing is also offered. Clients are required to sign a Release of Information as compiled by Telus Health, the online administrator of the direct billing program. Typically, to have services billed directly, your name, date of birth, and policy number will need to be released. Clients are provided with a copy of all claims made directly to their policy. At present, the only insurance companies allowing direct billing are Great West Life and Blue Cross. A predetermination of reimbursement is completed by the office manager once billing information is provided and should fees not be completed covered by insurance, a credit card will be billed for the additional amount.

Invoices not paid within 30 days will unfortunately have to be sent to a collection agency.

Confidentiality

Client privacy and confidentiality is the cornerstone of our business. This ensures a good working relationship between the psychologist and client. To that end:

All information gathered in the course of the assessment is considered confidential and as such, results of the assessment are only shared with the client and/or parents of minor children.

Parents are welcome to share the results of the assessment with their child’s teacher and/or physician. However, should they require the psychologist to forward the completed report, a written Release of Information will need to be signed by the client and/or parents.

Reports sent to a pediatrician’s office are done so electronically over Bright Squid, a medical software system. This program ensures privacy, and all files are encrypted with a password before sending.

All files are stored and maintained in a locked filing cabinet at all time as per the College of Alberta Psychologist’s standards of practice. Archived files are kept securely for a period of 10 years after completion of assessment and for minor children, two years past the age of majority.

Files transported out of the office for report writing purposes are kept in a secure file folder and briefcase, and are kept in a locked filing cabinet until returned.

Please note that all information gathered during the course of the interview will be included in the background information section of the report. Information gathered will be specific to the referral question, with irrelevant information being excluded. It is important to note that information provided by collateral contacts (i.e. family members, teachers, physicians) will be included in the report, unless otherwise requested.

I understand that all information will be kept in strict confidence, with the following exceptions:

The appropriate authorities must be informed if there are reasonable and probable grounds to believe that a client or other person will be harmed.

The appropriate authorities must be informed if there are reasonable and probable grounds to believe that a minor is in need of child protective services.

If the file is subpoenaed, the psychologist is obligated by law to release it.

Consent

Should parents share joint custody arrangements, consent from both parents is required before assessment can proceed. This is a legal requirement of our profession. Should parents wish to have a report amended, both parents must provide consent.

Should the client and/or parents of minor children wish to withdraw from the assessment, they may do so at any time in writing, with no penalty incurred.

This consent form is valid for one year should additional services be required.

Risks and Limitations

Information gathered during the course of assessment, such as observations or test results, may indicate the presence of additional difficulties that were unanticipated by the client and/or parents at the time of referral. This may cause some distress. Client concerns about this new information will be discussed.

In the case of gifted assessments, parents may discover that their child is not gifted, and that other educational placements will need to be considered. Gifted assessments are not meant to diagnose learning disabilities, ADHD, or autism; however, should information come to light during the assessment that would suggest the likelihood of such disorders, parents will be informed, and given the option of electing to have a more comprehensive assessment of their child completed.

Benefits

Given that this is a private assessment, parents own the report. This implies that they can choose to share it with their child’s school or physician at their discretion.

Once a diagnosis is provided, a copy of the report can be shared with various service providers in order to obtain specialized services. These services can include school support (IPP), funding support (FSCD, Disability Tax Credit), and/or other specialized services as recommended.

Flat rates are offered for all assessment services to ensure transparency in all financial matters. In cases when assessments are not as lengthy as expected, a lower rate may be offered.

Communication

Clients are able to contact Sharon Blott Psychological Services by phone/text (403-612-3396) or email at shblott@telus.net. Calls, texts, and/or emails received after 4:00 pm are returned the next business day.

An electronic copy of a report can be sent to the client when requested. Reports are encrypted with a password to ensure confidentiality. This password is sent in a separate email.

Intake and feedback appointments can be completed over Zoom if preferred.

COVID-19 Protocol

By attending in-person sessions, you are assuming the risk of exposure to the coronavirus. This risk may increase if you have travelled by public transportation, cab, or ridesharing service.

Your Responsibility to Minimize Your Exposure

To obtain services in person, you agree to take certain precautions which will help everyone stay safer from exposure, sickness, and possible death. Please initial each to ensure that you understand and agree to these actions:

INITAL

You will only keep your in-person appointment if you are symptom-free.

You agree to cancel your in-person appointment should you experience symptoms consistent with COVID-19. If you wish to cancel, the normal cancellation fee will be waived.

If a resident of your home tests positive or shows signs of the infection, you agree to advise us and reschedule your in- person appointment.

If you have been in contact with anyone that has tested positive for COVID-19 in the past 2 weeks you agree to advise us and reschedule your in-person appointment.

If you or anyone in your residence has travelled internationally within the past 2 weeks you agree to advise us and reschedule your in-person appointment.

You agree to adhere to the safe distancing precautions that have been set up in the waiting area.

Our Responsibility to You

Office seating in the waiting area and office has been arranged for appropriate physical distancing

Hand sanitizer is available in office for your use as are masks, should you decide to wear one.

Appointments are scheduled at intervals to minimize the number of people in the waiting area

The office is sanitized between each appointment

The Business Centre has increased their sanitization practices.

Should there be a resurgence of the COVID-19 virus, the above precautions could change as per municipal, provincial, or federal health guidelines. If this occurs, we will discuss any necessary changes.

This consent is valid for the course of the treatment and can be withdrawn at any time upon written request.

By pushing submit, I state that I have read the above form and provided my signature as agreement to the terms and conditions included.

(print your name)

give consent to Sharon Blott, Registered Psychologist at Sharon Blott Psychological Services, to provide Assessment Services to:

Westmount Charter School | Gifted and Talented Education (GATE)

ADHD/Learning Disability/Intellectual Disability

PDD, AISH, Disability Tax Credit, Capacity Assessment

About Your Psychologist

I am a Registered Psychologist within the Province of Alberta. My registration date was March 22, 2001 and my Registration number with the College of Alberta Psychologists is 2612. I have extensive experience working with children, teens, and adults, having worked for both the Catholic and Public School Boards in Calgary. As well, I was the Manager of Assessment Services at a private school that specialized in the education and support of students with learning disabilities. I have been in private practice since October 2010 and am in good standing with the College of Alberta Psychologists.

I Acknowledge and Consent to the Following:

Assessment

The assessment will involve the administration of standardized assessment measures as discussed in the intake interview. This typically includes a measure of intelligence (WPPSI-IV, WISC-V, WAIS-IV), achievement (WIAT- III), checklists for ADHD and executive functioning, as well as online and/or computer measures. The types of assessment measures completed will depend on the nature of the referral. The process of assessment is discussed during the intake meeting. Specialized assessment measures are administered for the assessment of Autism including the ADI-R and ADOS-II.

Please note that as per College of Alberta Psychologist guidelines, raw scores, and other such reports as produced by Pearson Clinical Assessments cannot be released directly to parents. Instead, all clinical information is interpreted by the psychologist and written into a comprehensive report.

Fees

Fees are billed in accordance with the current fee schedule as set forth by the Psychologists Association of Alberta. Fees are discussed during the initial consult and intake to ensure that clients are aware of the total cost of assessment. A flat rate is charged for all assessments to ensure transparency in all financial matters. An invoice will be provided for reimbursement. Effective April 1st, 2020, the fee is $200.00 per hour. Fees are as follows:

$500.00 initial fee | $900.00 if gifted (Westmount Charter School) | $1,500.00 if gifted (GATE)

$2,200.00

$1,000.00

$700.00

$3000 (Includes Psychoeducational Assessment)

A 30-minute fee ($100.00) is charged for no-show or late cancellation appointments.

Payment

The client and/or parents are responsible for fulfilling their financial obligation for the assessment. Payment is billed at the end of each session with an invoice provided for insurance reimbursement. The final balance owing is due at the last appointment in which a report is presented to the parents and/or client. All questions about billing should be directed to Sharon Blott.

Depending on your insurance provider, direct billing is also offered. Clients are required to sign a Release of Information as compiled by Telus Health, the online administrator of the direct billing program. Typically, to have services billed directly, your name, date of birth, and policy number will need to be released. Clients are provided with a copy of all claims made directly to their policy. A preauthorization is completed once billing information is provided and should fees not be completed covered by insurance, a credit card will be billed for the additional amount.

Invoices not paid within 30 days will unfortunately have to be sent to a collection agency.

Confidentiality

Client privacy and confidentiality is the cornerstone of our business. This ensures a good working relationship between the psychologist and client. To that end:

All information gathered in the course of the assessment is considered confidential and as such, results of the assessment are only shared with the client and/or parents of minor children.

Parents are welcome to share the results of the assessment with their child’s teacher and/or physician. However, should they require the psychologist to forward the completed report, a written Release of Information will need to be signed by the client and/or parents.

Reports sent to a pediatrician’s office are done so electronically over Bright Squid, a medical software system. This program ensures privacy, and all files are encrypted with a password before sending.

All files are stored and maintained in a locked filing cabinet at all time as per the College of Alberta Psychologist’s standards of practice. Archived files are kept securely for a period of 10 years after completion of assessment and for minor children, two years past the age of majority.

Files transported out of the office for report writing purposes are kept in a secure file folder and briefcase, and are kept in a locked filing cabinet until returned.

Please note that all information gathered during the course of the interview will be included in the background information section of the report. Information gathered will be specific to the referral question, with irrelevant information being excluded. It is important to note that information provided by collateral contacts (i.e. family members, teachers, physicians) will be included in the report, unless otherwise requested.

I understand that all information will be kept in strict confidence, with the following exceptions:

The appropriate authorities must be informed if there are reasonable and probable grounds to believe that a client or other person will be harmed.

The appropriate authorities must be informed if there are reasonable and probable grounds to believe that a minor is in need of child protective services.

If the file is subpoenaed, the psychologist is obligated by law to release it.

Consent

Should parents share joint custody arrangements, consent from both parents is required before assessment can proceed. This is a legal requirement of our profession. Should parents wish to have a report amended, both parents must provide consent.

Should the client and/or parents of minor children wish to withdraw from the assessment, they may do so at any time in writing, with no penalty incurred.

This consent form is valid for one year should additional services be required.

Risks and Limitations

Information gathered during the course of assessment, such as observations or test results, may indicate the presence of additional difficulties that were unanticipated by the client and/or parents at the time of referral. This may cause some distress. Client concerns about this new information will be discussed.

In the case of gifted assessments, parents may discover that their child is not gifted, and that other educational placements will need to be considered. Gifted assessments are not meant to diagnose learning disabilities, ADHD, or autism; however, should information come to light during the assessment that would suggest the likelihood of such disorders, parents will be informed, and given the option of electing to have a more comprehensive assessment of their child completed.

Benefits

Given that this is a private assessment, parents own the report. This implies that they can choose to share it with their child’s school or physician at their discretion.

Once a diagnosis is provided, a copy of the report can be shared by the parents with various service providers in order to obtain specialized services. These services can include school support (IPP), funding support (FSCD, Disability Tax Credit), and/or other specialized services as recommended.

Sharon Blott has over 20 years’ experience as a registered psychologist. Her work is well recognized as being of high quality, and reports are comprehensive and helpful for clients.

Flat rates are offered for all assessment services to ensure transparency in all financial matters. In cases when assessments are not as lengthy as expected, a lower rate may be offered.

Communication

Clients are able to contact Sharon Blott Psychological Services by phone/text (403-612-3396) or email at shblott@telus.net. Calls, texts, and/or emails received after 4:00 pm are returned the next business day.

An electronic copy of a report can be sent to the client when requested. Reports are encrypted with a password to ensure confidentiality. This password is sent in a separate email.

Intake and feedback appointments can be completed over Zoom if preferred.

COVID-19 Protocol

By attending in-person sessions, you are assuming the risk of exposure to the coronavirus. This risk may increase if you have travelled by public transportation, cab, or ridesharing service.

Your Responsibility to Minimize Your Exposure

To obtain services in person, you agree to take certain precautions which will help everyone stay safer from exposure, sickness, and possible death. Please initial each to ensure that you understand and agree to these actions:

INITAL

You will only keep your in-person appointment if you are symptom-free.

You agree to cancel your in-person appointment should you experience symptoms consistent with COVID-19. If you wish to cancel, the normal cancellation fee will be waived.

If a resident of your home tests positive or shows signs of the infection, you agree to advise us and reschedule your in- person appointment.

If you have been in contact with anyone that has tested positive for COVID-19 in the past 2 weeks you agree to advise us and reschedule your in-person appointment.

If you or anyone in your residence has travelled internationally within the past 2 weeks you agree to advise us and reschedule your in-person appointment.

You agree to adhere to the safe distancing precautions that have been set up in the waiting area.

Our Responsibility to You

Office seating in the waiting area and office has been arranged for appropriate physical distancing

Hand sanitizer is available in office for your use as are masks, which are mandatory

Appointments are scheduled at intervals to minimize the number of people in the waiting area

The office is sanitized between each appointment

The Smart Executive Centre has increased their sanitization practices.

Should there be a resurgence of the COVID-19 virus, the above precautions could change as per municipal, provincial, or federal health guidelines. If this occurs, we will discuss any necessary changes.

This consent is valid for the course of the treatment and can be withdrawn at any time upon written request.

By pushing submit, I state that I have read the above form and provided my signature as agreement to the terms and conditions included.

Registered Psychologist, to release/obtain information regarding the above- named client to/from the following:

Consent to release/obtain information is valid for one year.

By pushing submit, I state that I have read the above form and provided my signature as agreement to the terms and conditions included.