Form18 - [ FORM 18 Use the top of this page for your...

Info iconThis preview shows page 1. Sign up to view the full content.

View Full Document Right Arrow Icon
This is the end of the preview. Sign up to access the rest of the document.

Unformatted text preview: [ FORM 18 Use the top of this page for your letterhead.] Consent to Evaluation I agree to undergo (or I give consent for this person, , to undergo) a com- plete psychological/psychiatric/mental health/family evaluation at the direction of this third party: . I understand and agree that the results of this evaluation are to be the sole property of this third party. I agree that I will not hold this third party legally responsible for any events resulting from this evaluation or the records created by it. I understand that the purpose(s) of this evaluation are: 1. 2. 3. I understand and agree that no doctorpatient or therapistclient relationship exists or will be created between myself (or the person being evaluated) and the evaluator. I understand that I may withdraw my consent to this evaluation and to the transfer of information at any time by means of a written letter. However, I also understand that my withdrawal will not be retroactive (that is, it will not apply to testing and information transfer that have already taken place). If I do not withdraw my consent, it will automaticallyto testing and information transfer that have already taken place)....
View Full Document

Ask a homework question - tutors are online