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11Marie W. Wood, Ph.D., Clinical Psychologist
• Fayetteville, Arkansas 7270 • (479) 521-9696
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Informed Consent
Information: I will provide the best I have to offer in professional therapy services. If I
cannot provide you with the servic e you need, I will refer you to another professional. If
you need to contact me, please call 479 521-9696 and leave a message. In the event of
an emergency, go to the nearest hospital emergency room. If you are seeing another
mental health professional, let me know. Seeing more than one mental health
professional at a time may lead to confusion in therapy.
Nature of Therapy: Psychotherapy may vary depending on the issue the client brings to
therapy and the personality of the therapist. For therapy to be effective, it will require
change. You must be prepared to take an active role and be willing to look at the
problem from different points of view. I will take a history and gather information by
interview or homework assignments, short asses sment tools or a psychological evaluation
as needed.
Psychological Testing and Assessment: For psychological evaluations, I meet for an
initial session and you can expect several more face-to-face sessions for clinical
interviews and administration of s ome of the assessment instruments. I will give you
protocols to complete in the office as part of the assessment. Following these
appointments, I will set up a final meeting as an individual therapy session to go over the
results of the psychological evaluation and answer any questions you might have.
Payment: The fee for Individual therapy sessions is $150.00. The initial interview is
$200.00. Your payment or co-payment is due at the end of your 50 minute session.
My fee for the psychological evaluation is generally $900 for the assessment and
interpretation of the data. This amount may vary somewhat depending on the referral
question. Payment for the psychological evaluation is due at the time of receipt.
Insurance: For testing and/or therapy, it is the clients’ responsibility to talk to the front
office staff to determine if their insurance company requires pre-authorization and to
determine if I am on their provider panel. My office will file for insurance benefits,
however you are responsible for your bill. Your signature gives consent to provide
information to your insurance company.
Expert Witness: If you subpoena me as an expert witness in a court case, there will be a
standard fee charge, plus travel and preparation time.
Confidentiality: I am bound by the same confidentiality privilege as Attorney and
Client. Confidentiality will be honored with these exceptions for adults: If clients tell me
they wish to hurt themselves or others or abuse of a child, elderly, or handicapped person
is suspected. I am obligated to report these concerns. With minor clients, I make an
agreement with the parents and guardians that what is said in the session is confidential
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