Disclosure and Informed Consent Statement
Overview of Evaluation:
The agency that referred you to InMindOut Emotional Wellness Center, LLC for assessment (hereinafter referred to as “the employer”) has given you an offer of employment conditioned, in part, on the results of a job-related psychological assessment.Dr. Heather Ingram is the Licensed Psychologist who will be supervising the psychological evaluation, and a diagnostician or therapist will be administering the test.The assessment will consist of standardized written psychological testing, an oral interview, and a review of collateral or third-party information made available by the employer or by you. This may include information gathered during the background investigation you authorized the employer to conduct.
The assessment also will include a review of prior assessments if Dr. Ingram, a therapist, or a diagnostician previously evaluated you at InMindOut Emotional Wellness Center, LLC. Both the written inquiries and interview will probe public and private aspects of your life. These inquiries are necessary to adequately assess whether your psychological traits and abilities satisfy the requirements of the position you have been conditionally offered. If at any time you wish to ask about the relevance of any question asked in the interview—which will be scheduled sometime after completion of the written testing—please ask, and you will receive an explanation as to why the requested information is needed. As with any job application procedure, you have the right to terminate the assessment at any time.
Limits of Confidentiality:
Although the employer is the psychologist’s client, not you, the psychologist nevertheless will be mindful of his/her duty to conduct the evaluation with fairness and objectivity. You specifically understand and agree that you are not receiving treat mentor health care from the psychologist and that the psychologist does not consider him/herself to be treating you. You understand that you are not being examined for any purpose relating to your personal treatment or to your personal health care. Because the psychologist is conducting this evaluation at the request of the employer and for reasons having nothing to do with treatment or health care, you do not have doctor-patient or psychotherapist-patient privilege in your communications with him/her. Therefore, you understand and agree that anything you say or do during or in connection with the evaluation is entitled to disclosure, if relevant to the evaluation, and may or will be disclosed to others involved in the selection process who have a need to know it. The employer requires a report of pertinent findings and conclusions, including a determination of your suitability for this position, following the completion of the assessment.
The employer may authorize release of the records associated with this assessment, including any written report, to any other qualified professional. Circumstances leading to such an authorization may include a mandatory fitness-for-duty evaluation, disability claim, or other medical evaluation. State law also may require disclosure of otherwise confidential information for reasons associated with, but not limited to, risk of child abuse, a threat of serious harm to yourself or others, or court order. Some or all the information you provide may be used for psychological research concerning test validation, recruitment, selection, and performance of public safety employees. In the event information from your evaluation is used for research purposes, procedures will be put in place to help ensure that your identity is not revealed.
Report of Findings and Conclusions:
Following the completion of the examination, the psychologist will give the employer an oral and written report of relevant findings and conclusions relating to their opinion about your suitability for this position, pursuant to the attached authorization.These reports are necessary to fulfill the purpose for which you have been referred. The reports necessarily will contain private information, but the psychologist will make a good-faith effort to restrict the disclosure of private information to the minimum necessary to satisfy the purpose of the examination and to support his/her findings, conclusions, and recommendations. If the findings, conclusions, opinions, or recommendations are challenged in an adjudicative forum, the psychologist may make full disclosure of all information as may be necessary or required by law.
Waiver of Access to Report and Records:
This assessment is conducted solely to aid the employer in determining your qualification for hire. You will not be provided a copy of any report the psychologist provides the employer concerning your suitability. Because the employer is the client, your authorization will not permit the psychologist to release or disclose the report to you or any third party. You specifically waive any and all statutory rights to access and review personal health care or any other information as it pertains to this examination, if any, whether arising under state or federal statutory, regulatory or common law, including but not limited to, the Health Insurance Portability and Accountability Act of 1996, and the Texas Labor Code, and therefore have no rights to access or review the notes, reports, tests, analyses or other information generated in connection with this evaluation of your suitability for employment. Even if some of the information contained or produced in this assessment might otherwise be accessible to you, this information is inextricably interwoven with other confidential data to which you otherwise would not be entitled. Therefore, you agree to exonerate, release, and discharge InMindOut Emotional Wellness Center, LLC and the employer, its officers, agents, or assigns, from any claim or damages, whether in law or in equity, on behalf of yourself, your heirs, agents, or assigns, for their refusal to make available any and all information contained in this pre employment psychological evaluation other than the final determination (i.e., qualified or unqualified).
Payment for Services:
The employer is compensating the psychologist for service. However, the psychologist will remain objective and neutral. As such, s/he will have sole control over the examination and their resulting opinions, conclusions, and recommendations.
Potential Outcomes and Uses of the Examination Results:
As a result of this examination, the psychologist may conclude that you are (1) psychologically qualified for this position or (2) psychologically unqualified for this position. The employer has determined the standards and degree of suitability it requires for qualification. Regardless of the conclusions they reach and communicate in their report, the employer may choose not to rely on their findings and recommendation, in whole or in part, when deciding on your status. Alternatively, employer may rely entirely on their report. Thus, depending on their ultimate conclusions and recommendations concerning your suitability, and depending on the employer’s consideration of their conclusions and recommendations, the results of this examination may have a significant impact on your candidacy.
The psychologist’s opinion concerning your psychological qualification or suitability for this position is NOT a statement or opinion about your general psychological health or emotional stability, nor is it a statement about your suitability for this position with a different agency or for a different position with the same agency. Rather, it is a statement only about the degree to which the full range of assessment information available to them provides evidence at this time of the psychological traits and competencies required for the position.
Regarding Your Freedom to Decline to Participate:
You are free to decline participation in this examination. However, your decision not to participate in the examination will result in the revocation of the employer’s conditional offer of employment.
The psychologist will advise the employer to maintain the written report in a confidential medical file separate from other personnel information and that the information should be made available only to persons who have a bonafide need to know the information included in the report. Nevertheless, by signing the authorization attached hereto as Exhibit A and authorizing the psychologist to release this information to the employer, there is the possibility that the employer could redisclose this information. By signing the authorization, you will expressly release InMindOut Emotional Wellness Center, LLC , from any liability for the disclosure.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA, Title II, from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to any request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assertive reproductive services.
Recording and/or Photographing During the Evaluation:
You are not authorized or permitted to photocopy, photograph, record or capture any portion of the evaluation, in whole or in part, including but not limited to written testing, personal history questionnaires, oral interview, and conversations with Dr. Heather Ingram, a therapist, or a diagnostician from InMindOut Emotional Wellness Center, LLC, whether in-person or by telephone. This prohibition applies to all forms of recording, whether digital or analogue. By agreeing to proceed with this examination, you agree to accept this prohibition and any civil and/or criminal consequences for violating it.
Authorization to Use and Disclose Protected Health Information:
I authorize InMindOut Emotional Wellness Center, LLC to use and disclose their findings and opinions concerning my past, present or future physical or mental health or condition, as well as their conclusions, opinions, and recommendations as to my psychological qualification and suitability for the position I have applied for, to the agency that referred me for this examination (hereinafter referred to as the “employer”). This authorization does not authorize any of my prior or current health care providers to disclose personal health care records to InMindOut Emotional Wellness Center, LLC or my prospective employer without separate and specific written authorization, except as permitted by law.
Initial the following:
I understand that the psychologist will make a good-faith effort to restrict the disclosure of private information to the minimum necessary to satisfy the purpose of the examination and to support the findings, conclusions, and recommendations. Consistent with the provisions of state and federal law, I understand that the employer will be advised to maintain any written report provided to it by the
psychologist in a confidential medical file separate from other personnel information and that the information should be made available only to persons who have a bona fide need to know the information included in the report. I have been informed that I will not receive a copy of the written report, nor will I be able to authorize its release to any other person or party. I specifically waive any statutory rights to access and review personal health care information as it pertains to this examination.
I acknowledge that the psychologist has no control over how the employer uses the report once it receives it. I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer protected under federal law. I expressly release InMindOut Emotional Wellness Center, LLC from liability for that redisclosure. However, I also understand that federal or state law may restrict redisclosure of mental health information and drug/alcohol diagnosis, treatment or referral information.
Signature of Applicant:
You do not need to sign this authorization. However, your refusal will mean that the required psychological evaluation will not take place. This will result in the withdrawal of the conditional offer of employment.
You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. Any use or disclosure already made with your permission cannot be undone.
To revoke this authorization, please send a written notice, stating that you are revoking this authorization, to:
InMindOut Emotional Wellness Center, LLC
Dr. Heather Ingram
645 N. Walnut Ave.
New Braunfels, Texas 78130
I have read this authorization and I understand it.