Rebecca Elman, Ph.D., P.A.Licensed Psychologist
Contact Us561-470-8660
Forms

Gifted Assessment Forms

Read, sign, and submit the Doctor–Client Policies to Dr. Elman before your appointment. Then complete and approve the Background Information and School Communication forms. Submit those two signed forms together electronically to Dr. Elman. They are encrypted before they leave your browser. You may also download a copy for your records.

Doctor-Client Policies for Gifted AssessmentsComplete form

Rebecca Elman, Ph.D., P.A.
Licensed Psychologist
1875 NW Corporate Boulevard, Suite #100
Boca Raton, Florida 33431
(561) 470-8660 · rebeccaelman@gmail.com

Required fields are marked with an asterisk (*).

Welcome to my practice. The following provides important information regarding my policies for gifted assessments. Please review this information carefully and sign below to indicate that you have read and understood these policies.

Confidentiality:

Information you share with me will be kept confidential and will not be disclosed without your written authorization, except as required or permitted by law. Exceptions to confidentiality may include situations involving suspected child abuse or neglect, or when there is a serious risk of harm to you or another person. If consultation with another professional is necessary, I will make every effort to protect your privacy and limit identifying information whenever possible.

Evaluation Process and Release of Information:

The gifted assessment includes an evaluation of your child’s intellectual abilities and may also include a parent interview, behavioral observations, and review of relevant educational information. With your written authorization, I may communicate with school personnel and other professionals involved in your child’s care or education and obtain or provide information relevant to the evaluation.

Fee Policy:

Payment is due the morning of the evaluation after the assessment has been completed. Results will not be shared until payment is received. I accept Zelle, Venmo, check, and credit card. Payments made by credit card are subject to a 3% processing fee.

Cancellations and Missed Appointments:

If you need to cancel or reschedule your appointment, please notify Dr. Elman at least 48 hours before your scheduled appointment time. A $100 cancellation fee will apply if you cancel or reschedule with less than 48 hours’ notice or miss your appointment without providing notice. Following a late cancellation or missed appointment, a deposit equal to 50% of the evaluation fee is required before a new appointment can be scheduled. This deposit is separate from the $100 cancellation fee and will be applied toward the cost of the rescheduled evaluation.

Communication:

Please feel free to contact me with questions regarding the evaluation via phone or email. When I am unavailable, you may leave a confidential voicemail, and I will generally return calls within one business day.

Informed Consent:

I have read and understood the preceding information and have had an opportunity to ask questions. I understand the nature and policies of the evaluation and consent to enter into a professional relationship with Rebecca Elman, Ph.D., P.A.

Patient or Parent/Guardian’s Signature:

Click Sign and submit to email this policy and your signature. Your child’s information and the other forms are not included. You can download a copy for your records.

Background Information Form – Gifted AssessmentComplete form

Rebecca Elman, Ph.D., P.A.
Licensed Psychologist
1875 NW Corporate Boulevard, Suite #100
Boca Raton, Florida 33431
(561) 470-8660 · rebeccaelman@gmail.com

Required fields are marked with an asterisk (*).

Student Information

Student's Name:
Calculated from date of birth, in completed years.
Sex:

Reason for Referral

Who initiated the referral for gifted evaluation?

Family Information

Parent/Guardian 1:
Parent/Guardian 2: (optional)
Parents are:

Siblings:

Sibling 1

Name (optional)

Sibling 2

Name (optional)

Sibling 3

Name (optional)

Developmental and Medical History

Were there any significant complications during pregnancy, delivery, infancy, or early childhood?
Were your child's early developmental milestones generally achieved within expected timeframes?
Does your child have any significant medical, neurological, developmental, or psychological history that may be relevant to the evaluation?
Is your child currently taking any medication?
Has your child ever received speech/language therapy, occupational therapy, physical therapy, counseling, or other intervention?

Most recent hearing screening/evaluation:

Most recent vision screening/evaluation:

Does your child wear glasses or contact lenses?
Does your child have any fine-motor difficulties that could affect activities involving drawing, writing, or manipulating materials?

Educational History

Teacher: (optional)
Has your child received any advanced, accelerated, gifted, enrichment, remedial, or other specialized educational services?
Has your child previously undergone any psychological, psychoeducational, gifted, developmental, speech/language, occupational, physical, or other evaluation?

Social, Behavioral, and Learning Characteristics

Does your child have any significant difficulties with attention, impulsivity, anxiety, behavior, frustration tolerance, or adjusting to new situations?
Parent/Guardian Printed Name
Parent/Guardian Signature

Approving this form does not send it. When both forms are approved, submit them together using the encrypted submission button below. You may also download a copy for your records.

Authorization for Communication with Teachers and School PersonnelComplete form

Rebecca Elman, Ph.D., P.A.
Licensed Psychologist
1875 NW Corporate Boulevard, Suite #100
Boca Raton, Florida 33431
(561) 470-8660 · rebeccaelman@gmail.com

Required fields are marked with an asterisk (*).

AUTHORIZATION FOR COMMUNICATION WITH TEACHERS AND SCHOOL PERSONNEL

Dr. Elman may find it helpful to communicate with your child's teacher or other school personnel about your child's academic performance, classroom behavior, motivation, and learning needs. Please indicate whether you authorize this communication.

Please select one:

Dr. Elman will not contact your child's teacher or other school personnel unless you affirmatively select YES.

Child’s Name:
Parent/Guardian’s Signature:

Approving this form does not send it. When both forms are approved, submit them together using the encrypted submission button below. You may also download a copy for your records.

Background and school communication forms

Submit your completed forms

Complete and approve the Background Information and School Communication forms. Review the longer background form before approving it; the school form can be signed and approved in one step. When both are approved, generate a combined PDF and submit it electronically to Dr. Elman. You may also download a copy for your records.

  • Background Information Form – Gifted AssessmentNeeds approval
  • Authorization for Communication with Teachers and School PersonnelNeeds approval

0 of 2 forms approved.

Keep this page open until your submission is confirmed and you have downloaded any copy you want to keep. Leaving or refreshing this page clears your answers. These two forms are encrypted before they leave your browser when you submit them. Your policy acknowledgment is submitted separately.