Consent to Psychological Testing and Authorization
for Release of Confidential Information

I agree to undergo a Psychological Evaluation at the Center for Personal Development (CPD). I understand CPD is being hired by the agency below to complete this evaluation, but is not part of the agency. I understand that all information I provide, all tests I complete, and any observations of my behavior here can be included in the report of the evaluation. I understand that the results will be released to the person below, and will be seen by supervising staff at the agency below. I realize I can refuse to consent to this release, but that there may be consequences for doing so to my case.

I understand I have a number of rights under Illinois Law explained in The Notice of Illinois Psychologist’s Policies and Practices. Among these are that I have the right to a copy of the final report of the evaluation. I also understand that should I disagree with the conclusions of the report, I have the right to submit a two-page, typed, addendum to my file for consideration. If accepted, this would be stored with the report, detailing the reasons for my disagreement(s), and would then be sent with the report in the event it is released in the future. If the addendum is not accepted, I have the right to appeal this decision with the director of CPD, Dr. Steven Nakisher.

Further, I understand that the results and report of my evaluation, and records provided by the agency below will be retained in a file by CPD, and securely stored for several years. I realize that this information may be used to train future psychologists, or to conduct research on the effectiveness of these kinds of evaluations. In either case, any identifying information about me will be removed from the information so my privacy and confidentiality are protected.

By signing below, I consent to Psychological Testing under these terms.


(client name)
By signing below, I authorize CPD to release the results of the Psychological Evaluation of


(print client name)
to

(agency or person)

for the purpose of case and service planning. I understand I have the right to revoke this consent in writing at any time. The consent is valid for one year, ending on

______/______/______

This information may not be re-disclosed without my consent under Illinois Law.


(sign name)
to

(today's date)

This Consent and Authorization is governed by the Illinois Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110) as well as other applicable state and federal laws.