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Consent for Organizational Evaluation

I understand that I, or my child or other individual over whom I have signing authority, am participating in a psychological evaluation requested by or related to involvement with another agent, agency, or organization. In these kinds of evaluations, I understand that a report will be prepared and forwarded to the other entity or a specific representative. The report will go to the entity, and they will control its distribution. I will not receive a copy of such a report unless the other entity allows this

I understand, and have been informed, that there is no expectation of confidentiality, on my part, about this report. I am not engaged in a treatment relationship and am not a "client"/patient, in that sense. I am the subject of an evaluation. This report will be based on information gathered in interviews and/or testing, records review, and interviews with others who know about me. Information may not only be sought from others by the evaluator, but may have to be shared with others, when the evaluator needs to obtain someone's reaction to a fact or clarification is needed.

The information gathered in this process will be safe-guarded and treated with respect. If this evaluation involves more individuals than myself, it is my understanding that I have no right to access their information. If I wish for this information to be forwarded to another professional in the future, I understand I may have to approach the other entity for permission in order for that to occur.

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Clinician Signature: (office use only)