Arizona Forensic Services, LLC

Paul Simpson, Ed.D., Arizona Licensed Psychologist

doc@ArizonaForensics.com, Off (520) 355-1000, Fax (520) 355-2000,

www.ArizonaForensics.com

FORENSIC INFORMED CONSENT NOTICE

This Forensic Psychological Evaluation is being conducted at the request of the attorneys in your personal injury case. This evaluation is somewhat different than other psychological services. It is important for you to understand how a forensic evaluation contrasts from more traditional psychological evaluations.

Limited Confidentiality

While the results of this evaluation may or may not be helpful to you personally, the goal is to provide information about how you are functioning psychologically to your attorney, the respondent’s attorney, and/or the court.

In most cases, this evaluation is intended for use in some type of a legal proceeding. As such, the confidentiality of the evaluation and the results are determined by the rules of that legal system. If your attorney has requested this evaluation, s/he will receive a copy of our report and will control how it is to be used and who has access to it. If the respondent’s attorneys have requested the evaluation, a copy of our report will be sent to them and they alone will control the distribution of the report to yourself or other parties. If the court has ordered the evaluation, the completed report will be sent directly to the court, who will then determine distribution.

Once a decision has been made to use the report in a legal proceeding, the report and any information pertaining to it will probably be admissible into evidence as well as any other information that was provided concerning your mental health and functioning. If you have any concerns about the use or distribution of our report, you should discuss these issues carefully with your attorney. We cannot provide any legal advice or give early impressions about our evaluation.

It is important you know that the attorney, court or agency that requested the evaluation is our client and she/he/they have complete authority over the results, including whether or not any information will be released to you or to anyone else. In addition, because the evaluation was requested by another party and is not for the purpose of treatment or counseling, confidentiality may have fewer legal protections. We will not release the information unless instructed to do so by the person, court or agency that hired us or when we are legally required to do so.

Exceptions to this might include a determination on our part that you are dangerous to yourself, another person or if you reveal information that a child under the age of 18 has been abused. We would also have to release the evaluation if a court orders us to do so. There may be other examples where the laws require us to release the information obtained during the evaluation.

Voluntary Participation

Your participation in this evaluation is voluntary. We will not conduct the evaluation without your signature on this document. You also have the right to stop the evaluation at any time. But there may be legal consequences if you stop the evaluation; therefore, it would be in your best interest to consult with an attorney before doing so. In addition, if appointments are not kept or are cancelled within 24 hours of the appointment time, the person, court or agency requesting the evaluation will incur charges for the unused time that has been set aside for these services.

The Process

The evaluation itself generally consists of two separate parts: an oral interview and psychological testing. In addition, it is normally necessary for us to review other related material such as court records, depositions, transcripts, medical records, or collateral interviews. “ Collateral interviews” are often a part of the evaluation and involve talking with a family member or friend who can provide information about your history. You are encouraged to submit the names and contact information of collateral sources who can provide relevant and reputable information. This is voluntary on your part.

If, at any time, you have a question about any aspect of the evaluation or these procedures, please feel free to ask us. In addition, if at any time you need a comfort break during the evaluation, please let us know. Once the evaluation is completed, and with the permission of the requesting party, we might be able to have a meeting with you to explain the results and answer any questions you might have.

This document has legal consequences and you should consult with your attorney before signing if you do not understand any portion of it.

I have read and agree to the above.