Raymond J.
Havlicek, Ph.D.
Psychologist
Forensic & Clinical Psychology
Diplomate in
Clinical Psychology
Fellow,
220 South
Service Rd. Suite 23
Roslyn
Heights, NY 11577
&
30 Cayuga
Way
Lake Placid,
NY 12946
516-484-5388v
518-441-9426v
516-776-9275f
Attorney for Defendant: _______________
Attorney for Plaintiff: ________________
Attorney for
the Child:
Information
provided regarding efforts to obtain informed consent prior to inception of
forensic evaluation and retainer agreement:
Mr. and Mrs.
_______________
(the adult participants/litigants) have been informed that this is a court
ordered evaluation of this family.
I asked the participants whether or not they have read and understood the court
order requiring the evaluation. Both stated that they have read and understood
the court order for a forensic psychological evaluation. I informed the
participants that this process is not therapy, but rather an
information gathering process, which ultimately results in the provision of
information and recommendations to a court (or the party’s attorneys).
I informed the parties that any suggestions made in the context of this
procedure are made solely for the purpose of evaluating the party’s responses. I
informed both participants that any and all information gathered as the result
of this procedure, including written transcripts of interviews and psychological
test results may and probably will be conveyed to the court (or the parties’
attorneys), and in that sense there is only
limited confidentiality. In addition,
I told both litigants that information is not provided to other parties who have
no association with the court (or with the parties’ attorneys) unless I am
specifically directed to do so by the court (or the parties’ attorneys).
Both participants/litigants were informed that an area in which there is
no confidentiality involves the issue
of suspicion of child abuse.
I explained to both participants/litigants that suspected child abuse must be
reported to Child Protective Services in accordance with
I asked
Mr. and Mrs. _______________ if they fully
understood that they will be participating in a forensic psychological
evaluation procedure, in keeping with the court’s requirements.
I informed the adult participants/litigants that no further assessment
would be conducted unless both adult participants stated they fully understood
the descriptions of the process provided and that their verbal and written
informed consent to continue was obtained.
Mr. and Mrs.
_______________
were told to produce any and all information (i.e. facts,
observations, memories, feelings, beliefs, the opinions of physicians,
psychologists, therapists, and other professionals as may be deemed relevant and
appropriate) to the attention of this psychologist, in order to properly
complete this forensic psychological evaluation.
Both Mr. and Mrs. _______________ were
informed that while this evaluator will make every effort to obtain all relevant
information, ultimately it is their
responsibility to ensure that this evaluator has been informed of any and
all relevant information necessary for this psychologist to formulate an
objectively and comprehensively
determined forensic conclusion. Both adult participants/litigants were informed
that they may communicate any information from whatever source to this evaluator
through the use of interviews, letters, recordings, pictures, drawings,
facsimile, and e-mail. E-mail was
described as the preferred method for transmitting written material.
Both litigants were informed that they
should provide me with a list of professionals they wish me to contact for the
purpose of obtaining their opinions regarding any aspect of the current
assessment.
Both adult
participants/litigants were informed that the forensic psychological findings of
this evaluator are merely the opinions
of one psychologist, and that forensic psychologists are evaluators who make
recommendations, not judges.
Both Mr. and Mrs. _______________ were
informed that irrespective of the adult participants’/litigants’ approval or
disapproval of the opinions and recommendations of this evaluator, there is at
all times the option for negotiations through legal representatives, mediation,
and settlement efforts, based on the opinions of the parties in consultation
with their legal representatives, and if all else fails, a full hearing before a
judge who can and will decide the case.
Both
Mr. and Mrs. _______________ were informed
that in the event of disputes arising in the context of this evaluation, the law
guardian is to be contacted should a party seek guidance, since this evaluator
is entirely neutral and should not provide recommendations until the forensic
process has been concluded. I
explained that when possible outcomes
are discussed prior to the conclusion of this forensic evaluation, they are to
be considered hypothetical possibilities only, mentioned ONLY for
the purpose of the assessment. I
further explained that all recommendations are made only to the court and that
referrals will be made if this evaluator is asked to by the court.
Both
litigants were informed of the cost of the procedure as well as the portion of
the cost each party is responsible for in keeping with the order of the court.
Both adult litigants were informed of the $_________ retainer and costs of the
forensic procedure as well as how much each party will pay as ordered by the
court. Court testimony fees of
$________ per day were described, as well as the necessity for payment in
advance of testimony. A retainer deposit of $_________ was requested, and
$________ (____%
as ordered) was received from Mr.
_______________.
Mrs.
_______________ is responsible for ___%
or $_________ of the initial retainer. Additional costs will be charged if the initial
retainer is exceeded. An additional _______ was billed and received from
___________. I explained that an hourly rate of
$250 would be charged against the
retainer for any and all charges incurred in the production of this report,
not including the costs of tests and other materials, which may be necessary.
The adult participants/litigants were informed that time spent analyzing
information and writing the report will be billed at the rate of
$250 per hour. An additional
$________ (to be filled in at conclusion) in charges were billed and paid
for, by the parties; total cost for the evaluation was $____________.
This figure includes $___________ in disbursements for the cost of ______
psychometric administrations; in addition to a $________ printing and delivery
charge. Both parties were informed that all cancelled or missed appointments
will be billed in the amount of $250 unless
48 hour prior notification of the decision to cancel the appointment is
provided. Both parties were informed that once Dr. Havlicek has been
scheduled to testify in court, he must be paid $___________, at least one week
in advance of his scheduled testimony. No refund of the $_________ will be made,
should notice of cancellation of trial testimony be made within 24 hours of the
scheduled court appearance. Both parties were informed that should a check be
returned for any reason, the party writing the check will be charged $100.00.
Once a check is returned, the forensic procedure is stopped until all unpaid
fees are paid in full by certified
check. Additional trial preparation fees will be charged at the rate of
$250 per hour. All unpaid fees for
forensic services beyond the initial retainer must be
paid in full prior to the
submission of the report to the court.
The
methodology of the procedure was described as follows: Initial interviews will
be transcribed and then either read back or checked for accuracy of content with
each adult litigant at subsequent appointments, in order to ascertain the
accuracy of the interview summary. I explained that modifications of interview
summaries will be made in keeping with the corrections made by each adult
participant in order to ensure that each litigant’s views are accurately
and reliably described. I further explained that interview summaries
will be listed in the final report to the court, and that copies of significant
and relevant notes will be reproduced as accurately as possible and listed in
the report to the court. Video and audio recordings of interviews and meetings and
parent-child interactions may be made at any time within my office, including my
waiting room or anywhere. The parties will be informed in advance if any
recordings will be made. I also explained that test results will be described in
the report and that appendices will be used for all other sources of
information, as well as lengthy psychometric test results. I explained that the
validity and reliability of all psychometric instruments would be described and
that recommendations will be listed as well as substantiating,
validating/falsifying data at the end of the report. Both parties were informed
that video and audio recordings of interviews, parental interactions with each
other and with their children, and of home settings may be made.
Both
litigants were informed that Dr. Havlicek will not engage in conversations with
the parties’ attorneys once the procedure is commenced.
Statement
summarizing information provided to the litigants regarding forensic procedures:
Both
litigants read and listened to me read and/or explain the above information to
them. Both litigants stated that
they fully understood the information presented and that they are voluntarily
agreeing to participate in the evaluation in compliance with the court’s order.
Both litigants were informed that the findings and recommendations of this
evaluation may or may not be consistent with their own views regarding what each
believes should happen. Both litigants’ signatures below indicates each
litigant’s expressed acknowledgement that they fully understand the descriptions
of the procedure and that each litigant has provided their full and
unconditional informed consent to proceed with the forensic evaluation.
Both
litigants were informed that this evaluator must attempt to secure information
from other persons and/or professionals and/or agencies in order to perform an
objective and comprehensive evaluation. An authorized request form
appears below. Each litigant approved of the generic (i.e., can be sent to
anyone) authorized request form, following a careful reading of the authorized
release form as indicated by his or her signatures. Each litigant was informed
that copies of the generic authorized request form might be made and sent to
whomever Dr. Havlicek decides to contact for information.
Both litigants were asked to provide the names and addresses of
individuals and/or professionals and/or agencies from which information should
be obtained.
Both
litigants were informed of the cost of the procedure, including the hourly rate
for time spent in the preparation of the report. Both litigants were informed
that all costs for the evaluation must be paid prior to submission of the report
to the court.
SIGNATURES OF EACH LITIGANT ACKNOWLEDGING THEIR INFORMED CONSENT TO PROCEED WITH
THE FORENSIC EVALUATION PERSUANT TO THE ORDER OF THE COURT APPEAR BELOW.
NOTE TO EACH LITIGANT: PLEASE CAREFULLY READ THIS DOCUMENT BEFORE
SIGNING. YOUR SIGNATURE MEANS THAT YOU HAVE UNDERSTOOD
I hereby
unconditionally agree to all the terms of this evaluation as described above and
below. I have carefully read all the information contained in this document and
have asked Dr. Havlicek to explain any issues and/or descriptions not completely
understood by me. I NOW FULLY UNDERSTAND
__________________________________________________________________
(Mother's
Signature)
(Date)
(Print Name)
**************************************************************************************************
I hereby
unconditionally agree to all the terms of this evaluation as described above and
below. I have carefully read all the information contained in this document and
have asked Dr. Havlicek to explain any issues and/or descriptions not completely
understood by me. I NOW FULLY UNDERSTAND
_______________________________________________________________
(Father's Signature)
(Date)
(Print Name)
****************************************************************************************************
Raymond J.
Havlicek, PhD
Psychologist
Forensic &
Clinical Psychology
Diplomate in
Clinical Psychology
American
Board of Professional Psychology
Fellow,
American Academy of Clinical Psychology
220 South
Service Road, Suite 23
Roslyn
Heights, NY 11577
516-484-5388
516-776-9275
(fax)
&
30 Cayuga
Way
Lake Placid,
NY 12946
518-441-9426
516-776-9275
(fax)
CONSENT TO
OBTAIN AND DISCLOSE INFORMATION:
This form
when completed and signed by you, authorizes the release and exchange of
protected information from your clinical record to the person(s) you designate
RE:
_______________ v _______________, Parenting
Coordination or Court Ordered Forensic Evaluation (fill in name of
case)
Client/Patients’ Last Name: _______________
Parties’
First Names: _____________(Father);
_____________
(Mother);
Additional individuals: _________________DOB:_____________
_________________ DOB:_____________
_________________ DOB:________________
__________________DOB:________________
Concerning
the medical/psychological/educational records of the above, I the undersigned,
hereby authorize Raymond J. Havlicek, PhD to:
X Obtain information from
X Give information to
X Obtain information and give information
X Both by phone and in written
form
X
Information
will be provided to Dr. Havlicek by any individual Dr. Havlicek sends a copy of
this release to. Information will
be provided to any individual or agency Dr. Havlicek elects.
*For
the purpose of furthering either the psychological evaluation of the above
client(s), or their Parenting Coordination, I understand that this authorization
is for the purpose of receiving and providing information. All diagnostic and
therapeutic information may be included with the following exception(s) (check
as appropriate):
X
No
exceptions
__ Treatment
for drug and alcohol abuse
__ Specific
diagnostic information (specify):______________________________
__ Specific
treatment information (specify):______________________________
__ Other
(specify):_________________________________________________
**
I understand that information obtained pursuant to this authorization may be
subject to re-disclosure by the recipient of your information and as such is no
longer protected by HIPAA Privacy.
*** I
understand that this release will remain in effect until this case has been
settled, closed or decided.
Date:_____________Signed by Mother:______________________________________________
Date:_____________Signed by Father:______________________________________________
Date:_____________Signed by Dr. Havlicek__________________________________________
Dr. Raymond
Havlicek
Witness
If you
downloaded this form please read it, sign it, and fax it to: 516-776-9275,
attention Dr. Havlicek