MARY A. CONNELL, ED.D., ABPP

Diplomate in Forensic Psychology

I do hereby express my understanding that interviews with Dr. Connell may be audio or video taped and that these audio tapes or video tapes will become a part of the record of evaluation. I further understand that they will be treated with the same degree of security as will other documents and materials related to by evaluation. I have no objection to the tapes being made and being retained as part of my (or, if signing as a parent or managing conservator, my child’s) file.

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Client, Parent, or Managing Conservator                        Date signed

MARY A. CONNELL, ED.D., ABPP

Diplomate in Forensic Psychology

I understand that from time to time it may be helpful, for research and training purposes, to rely upon actual data from clinical or forensic practice. I also understand that when this is done, the data or material is "de-identified" to conceal the identity of the person(s) about whom the data relates, and that this is done carefully and thoroughly, so that no accidental recognition of the data might occur. I do/do not give my consent for the data gathered from me or about me (or, if signing as parent or managing conservator, my child) to be used for research or training purposes. I understand that I am absolutely free to refuse the release of materials for this purpose, and that my electing to refuse this consent would in no way affect the outcome of this assessment process.

Client, Parent, or Managing Conservator                             Date