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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)....
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- Spring '10