Telepsychology Docusign Forms
This is for clients doing part or all of the evaluation via a telehealth model.
Setting up for Telehealth – printable pdf instructions
TeleHealth Agreement – Docusign Version – Telehealth agreement, Hipaa Consent, General Insurance waiver
Authorization – DocuSign Version – Permission allowing communication with third party i.e. therapist, pediatrician, other professional
18+ Client permission to communicate with Parent/Guardian – Docusign Agreement – Additional for clients 18 years old or older, granting permission to discuss evaluation details with their parent(s)/guardian(s).
Consent to complete evaluation in person Docusign Version – This is to be signed if the entire evaluation can not be completed via Telehealth and additional testing will be needed to completed in person.
CNS Pediatric Questionnaire PDF Version for printing (Questionnaire about child’s school, family, medical history. Note: There is no Docusign version of this form)
Consent Forms PDF Version for printing (Hipaa Compliance required. Please note if you filled out the Docusign Telehealth agreement this printable version does not need to be completed)
Authorization PDF Version for printing (Permission allowing communication with third party i.e. parent,therapist, pediatrician, other professional. Please note if you filled out the Docusign Authorization form this printable version does not need to be completed.)
Forms are written as PDF documents and require Adobe Acrobat to download and access. If you do not have Adobe Acrobat click here.
Any form that was printed and filled out should be mailed to:
Children’s Neuropsychological Services
26 Chestnut Street, Suite 2E
Andover, MA 01810