Consent Form - New Zealand

This form contains standard consent information for neuropsychological assessment and treatment in New Zealand, including reference to the Code of Health & Disability Rights. The form allows you to add additional consent items, as required. You can print/save the form for signing or it can be signed on touchscreen devices.

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Consent to Neuropsychological Assessment

Client Information

Client Name

Date of Birth

Cultural & Identity Considerations

Identity or cultural practices to acknowledge

Understanding Your Rights

I understand the reasons for my referral to neuropsychology, the role of the neuropsychologist, and I agree to being assessed and/or treated by neuropsychology staff.

I have had the likely risks and benefits explained to me.

I understand that neuropsychologists collect and store my information as part of an electronic and/or hardcopy of my health record. I understand that I can request copies of my information but that some elements (e.g. copyrighted test information) cannot be shared.

I understand that information I share with my neuropsychologist remains confidential, except in cases of legal or safety requirements, or for supervision purposes.

I have been informed about the Code of Health & Disability Services Consumers' Rights and how to make a complaint.

I understand that I can withdraw my consent at any time.

Standard Consent Items

I agree that my neuropsychologist can contact my GP and/or:

I agree for the following person to be contacted:

I consent to elements of my session to be recorded/transcribed on these dates:

In case I see my neuropsychologist in a different context (e.g. in the street), we've discussed whether/when/how we will acknowledge each other.

Additional Items

Signatures

Client Signature

Sign & Date.

Psychologist Signature

Sign & Date.