Informed Consent for Clinical Documentation Evaluation

Provider: Christopher Sims, LPC, LPCC

Purpose of the Evaluation

This service provides a brief clinical evaluation to determine whether documentation supporting certain requests may be clinically appropriate. These requests may include documentation related to emotional support animals (ESA) or workplace accommodations.

The evaluation consists of completing an online questionnaire regarding mental health history, symptoms, functional impairment, and other relevant information. Based on the information provided, the clinician will determine whether clinical documentation can be issued.

Nature of the Service

This service is not psychotherapy and does not establish an ongoing therapeutic relationship.

The purpose of this evaluation is limited to determining whether documentation supporting a request may be clinically appropriate at the time of the evaluation. The clinician does not provide ongoing treatment, diagnosis confirmation for medical records, or long-term mental health care through this service.

If you are seeking therapy or ongoing mental health treatment, you should seek care from a licensed mental health provider who offers those services.

Eligibility

Services are provided only to individuals who:

• are 18 years of age or older
• are physically located in Pennsylvania or California at the time of the evaluation
• provide accurate and complete information during the evaluation process

Providing false or misleading information may result in denial of documentation.

Possible Outcomes of the Evaluation

After reviewing the submitted information, the clinician may determine that:

• documentation supporting the request is appropriate, or
• documentation supporting the request is not clinically appropriate

Payment for the evaluation covers the clinician’s time reviewing the information and conducting the assessment. Payment does not guarantee that documentation will be issued.

Limitations of Documentation

If documentation is issued, it reflects the clinician’s professional opinion based solely on the information provided during the evaluation.

Third parties such as employers, landlords, or housing providers ultimately decide whether to grant requested accommodations. The clinician cannot guarantee that any accommodation or request will be approved.

Communication with Third Parties

The clinician provides documentation only to the client. The clinician does not communicate directly with employers, landlords, housing providers, or other third parties regarding the evaluation.

Confidentiality

Information provided during the evaluation will be treated as confidential and handled in accordance with applicable privacy laws and professional standards. A separate Privacy Policy explains how information is collected, stored, and used.

However, confidentiality may be limited in situations required by law, such as:

• risk of serious harm to yourself or others
• suspected abuse or neglect of a child or vulnerable person
• court orders or other legal requirements

Electronic Communication

Documentation is delivered electronically, typically via email as a PDF document or secure download link. By using this service, you acknowledge that electronic communication carries some risk of interception or unauthorized access.

Client Responsibilities

By proceeding with this evaluation, you agree that:

• the information you provide is accurate and complete
• you understand that documentation may be denied if clinically inappropriate
• you understand that this service is not therapy or ongoing treatment

Acknowledgment and Consent

By checking the agreement box and proceeding with the evaluation, you acknowledge that:

• you have read and understood this Informed Consent
• you agree to participate in this evaluation under the terms described above