Informed Consent for Psychological Assessment

Record #

Informed Consent for Psychological Assessment[i]

Please check each item below to indicate that you have read it carefully and understand it.

  • I understand that Dr. Pacheco has been appointed by the court, by me, by my attorney, and/or by an authorized party to conduct a psychological assessment and a clinical interview of myself and/or of the person(s) I hereby authorize, as follows:



  • I understand that Dr. Pacheco intends to conduct interviews as required and administer psychological tests, that written notes will be taken throughout the process, and that, at the option of Dr. Pacheco, the sessions may also be audio and/or video recorded.
  • I understand Dr. Pacheco will score, interpret, and write a formal report about me and/or the person(s) I have authorized, based on the results of the psychological tests and interviews.
  • I understand that a psychological assessment is based on the interpretation of the findings from the psychological tests and interviews, and that an impartial report will be written which may or may not support my best interests.
  • I authorize Dr. Pacheco to submit a copy of this formal report to the court, to my attorney, and/or to the person or institution it is intended for, and to discuss the results with such person(s).
  • I understand that Dr. Pacheco WILL/WILL NOT provide me with a copy of this written report.  I may, if I choose, schedule an additional appointment with Dr. Pacheco to discuss the results of the assessment.
  • I authorize Dr. Pacheco to testify about me and/or the person(s) I have herein authorized, and about this assessment, in depositions and trial(s) related to legal case(s) I and/or the authorized person(s) may be involved in.
  • I understand that if I disclose certain types of information to Dr. Pacheco and/or to his Assistants and Collaborators, he or she may be required to communicate this information to other people.  As previously discussed with Dr. Pacheco, examples of such special information include reports of child or elder abuse, intent to kill myself, and threats to kill or violently attack a specific person.


If you have read, understood, and checked off each of the previous sections, please read carefully the following statement and, if you are in agreement, please sign the statement.

Do not sign if you have any further questions or if there are any aspects that you don’t understand or agree to; contact your attorney for guidance concerning how to proceed so that you fully understand the process and can decide whether you wish to continue.

Consent Agreement: I have read, agreed to, and checked off each of the previous sections.  I have asked questions about any parts that I did not understand fully.  I have also asked questions about any parts that I was concerned about.  By signing below, I indicate that I understand and agree to the nature and purpose of this assessment, how it will be reported, and to each of the points listed above.


Printed Name                                                             Signature                                                             Date




[i] Adapted from Pope, Kenneth S., Butcher, James N., & Seelen, Joyce (2006).  The MMPI, MMPI-2, and MMPI-A in Court, Third Edition.  Washington, D.C.: American Psychological Association.




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