Informed Consent/Notice of Forensic Services (Adult)

Date/Time: [Date and time of evaluation]

Location/Modality: [in-person / video / phone]

Evaluator: [Evaluator name, credentials, organization, contact information]

Evaluee: [Full legal name, DOB]

Identity Verified: [yes / no], [method used] (If not verified, document as incomplete and describe attempts made.)

Case/Matter: [Case caption/docket number if litigation, or brief administrative context]

Jurisdiction/Court/Agency: [Name of court, agency, or jurisdiction] (Omit if not applicable.)

Parties and Roles

• Retaining Party: [Name], [court / defense counsel / plaintiff counsel / prosecutor-government / employer / insurer / other]
• Retaining Party Contact: [Contact name, phone, email]
• Evaluee Represented by Counsel: [yes / no / unknown] (If yes, include counsel name and contact. If unknown, document whether evaluee was advised to consult counsel.)

Client of Evaluator: My client is [retaining party], not the evaluee.

Role Clarification: Although I am a licensed clinician, this evaluation is performed for a forensic purpose. I am not serving as the evaluee's treating provider.

Type of Authorization

(Select and complete exactly one subsection below. Delete the inapplicable subsection.)

Voluntary / Consent-Based Evaluation

• Participation is voluntary: yes
• Informed consent obtained: [yes / no]
• If consent not obtained, disposition: [rescheduled / terminated / retaining party notified] (Omit if consent was obtained.)

Court-Ordered / Mandated Evaluation

• Ordered or mandated by: [Court, agency, or authority name]
• Order date: [Date], Copy reviewed: [yes / no]
• Notice provided to evaluee: [yes], [how and when provided]
• Evaluee advised that refusal or non-participation may be reported: [yes / no]

Purpose and Scope

Purpose: [Brief statement of the legal or administrative question to be addressed]

Scope: [Planned components: interview, mental status examination, psychological/psychiatric testing, record review, collateral contacts] (List only those applicable.)

What this evaluation is not: This is not treatment, not a second opinion for clinical care, and not an emergency service.

Expected products: [Written report / possible testimony / consultation with retaining party] (List applicable items.)

Known limitations: [Time constraints, incomplete records, limited collateral access, other] (Omit if none.)

Anticipated Uses and Confidentiality

• Intended recipients: Retaining party. Other foreseeable recipients: [court or agency decision-maker / opposing counsel or other parties / experts working with retaining party / other] (List all applicable.)
• Use in proceedings: Information may be used in legal or administrative proceedings and may become part of discoverable materials or public record if filed or presented in testimony. Once disclosed, control over further distribution may be limited.
• Limits of confidentiality explained: This is not a confidential therapy session. Information shared may be included in the report and disclosed in legal or administrative proceedings. Therapeutic privilege expectations do not apply. Privilege (if any) is governed by the legal context and may be held by someone other than the evaluee. Release of evaluator records may be controlled by the retaining party and court orders. Subpoenas or court orders may compel disclosure.
• Mandatory reporting discussed: [Threats of serious harm to self or others / child, elder, or vulnerable adult abuse or neglect reporting / other legally required disclosures per jurisdiction]

Voluntariness and Right to Decline

• (For voluntary evaluations) The evaluee was informed that participation is voluntary and they may stop the evaluation at any time.
• (For mandated evaluations) The evaluee was informed they may refuse to answer questions; the evaluation may proceed using records and collateral sources; refusal or non-participation may be noted in the report.
• (For all evaluations) The evaluee may decline to answer specific questions; such declinations may be documented when relevant.
• Evaluee requested to contact counsel before continuing: [yes / no / not applicable] (If yes, document whether permitted and outcome.)

Procedures and Sources

• Interview components: [Clinical history, psychosocial history, mental status examination, risk assessment, other] (List applicable components.)
• Testing: [Categories of psychological/psychiatric tests] (Omit if no testing performed. May describe categories rather than specific instruments if test security is a concern.)
• Record sources to be reviewed: [Medical, therapy, employment, school, legal/court, law enforcement, military, benefits/insurance, other]
• Collateral contacts planned: [Names/roles or categories] (Collateral sources will be informed of who retained the evaluator, the purpose of the evaluation, and limits of confidentiality. Omit if none planned.)

Recording and Third-Party Presence

(Include this section only if applicable.)

• Session recording: [audio / video / none], by [party], for [purpose] (Include policy regarding surreptitious recording if relevant.)
• Third party present: [interpreter / observer / trainee / security officer / other], role: [role description] (Omit if none present.)
• Interpreter: [Language], [in-person / remote]. Confidentiality expectations and evaluation purpose were explained to the interpreter. (Omit if no interpreter used.)

Financial Responsibility

• Payer: [retaining party / evaluee / government agency / other]
• If evaluee is responsible: [Hourly or flat fee], [estimated cost range], [cancellation policy] (Omit if evaluee is not financially responsible.)
• Fees are not contingent on the outcome of the evaluation.

Records

Records from this evaluation (notes, test data, recordings, report) are typically accessible to the retaining party. Others may obtain access through legal process or with authorization from the retaining party. Records are retained per organizational policy and applicable law. Direct records inquiries to the evaluator's office.

Comprehension and Acknowledgment

• Opportunity to ask questions: [yes / no]
• Questions answered: [yes / no / no questions asked]
• Comprehension check: [Evaluee's own-words summary demonstrating understanding that this is not treatment or a confidential therapy session and that the report goes to the retaining party] (If comprehension appears inadequate, document observed basis and next steps taken, such as involving legal representative or notifying retaining party. Document as incomplete if comprehension could not be verified.)

Signatures

Evaluee: [Signature] or "Refused to sign—notice provided orally," Date/Time: [Date/time]

Evaluator: [Signature], Date/Time: [Date/time]

Witness: [Name/Signature], Date/Time: [Date/time] (Optional; recommended for high-stakes situations, language barriers, custody settings, or contested voluntariness.)

Interpreter: I attest that I accurately interpreted the information provided. [Name/Signature], Date/Time: [Date/time] (Include only if interpreter used.)