Psych Assesment Consent Form

Request to for Clinical Assessment for a Case Study
Study Title: PSYCHOLOGICAL ASSESSMENT
Student Investigators: Jamolin, Joana Margarette F.
Dear ______________,
I hope this letter finds you well. I would like to ask your permission to execute a Psychological
assessment and an interview for a case study. The case study will be presented to number of
professionals, and the interview will include numerous psychological tests, medical background
checks of not only the client but also the people involved (e.g. family, relatives), mock diagnosis (via
DSM-V) though the information about the case would be educational for other physicians and
health care workers. If you agree to allow us to use your medical record for this study, we would
need to access the following types of information: age, medical conditions, demographics.
Your decision to allow your health information, interview to be used for a case study is entirely
voluntary. You are free to say no without any impact on your current or future treatment. Although
you will not benefit directly from allowing your case to be presented, this information will help to
advance our understanding of Psychological Evaluation.
Privacy and Confidentiality

Although there is always a slight risk of loss of anonymity when working with personal health data,
your privacy will be respected and all reasonable efforts will be made to protect your information.
Only the interviewee and myself will have access to information identifying you. All of the data used
for this study will be de-identified, which means that information such as your name, medical record
number, and Saskatchewan health card number will not be included in the database or in reports of
the results.
While working on the project, your de-identified data may be kept on a password protected USB
drive used by the investigators, which will be locked away when not in use. Data will be stored on
password-protected computers in the offices of Psychological Department of Mapua University and
myself and will be permanently destroyed five years after the results have been published.
Deciding to Withdraw
If you agree to allow us to use your information for this case study and then change your mind, you
may ask us to remove your data. This decision will not affect your care in any way. We can
accommodate this request up until we have started analyzing your data. After this point, it may not
be possible to withdraw your information.
For More Information

You may see a copy of the final case study if you wish. If you have any questions, you may speak to
me at the phone number listed above.
Psychological Assessment
Request to Use Health Information for a Case Study, Version 1, [17/12/19] 1
If you give permission for the individual(s) listed above to use your personal health information for
this case study, I kindly ask that you sign the next page and return a copy to me in the postage paid
envelope enclosed. You may also contact [Jaolin, Joana Margarette F.] at
[joanajamolin01@gmail.com| 09278162511] if you agree to allow your medical background as well
as the interview executed to be used for this case study, I will document your permission for our
records.
If you do not give permission, no action is required on your part.
Sincerely,
Jamolin, Joana Margarette F.

Student, Mapua University
Consent Statement
Study Title: PSYCHOLOGICAL ASSESSMENT
 I have read (or someone has read to me) the information in this consent form.
 I understand the purpose and procedures and the possible risks and benefits of the study.
 I was given sufficient time to think about it.
 I had the opportunity to ask questions and have received satisfactory answers.
 I understand that I am free to withdraw from this study at any time for any reason and the
decision to stop taking part will not affect my future relationships.
 I give permission to the use and disclosure of my de-identified information collected for use
in this case study, as described in this form.
 I understand that by signing this document I do not waive any of my legal rights.
 I will be given a signed copy of this consent form.
__________________________________
Name of participant/patient (please print)
__________________________________ ________________________
Participant/patient signature Date
__________________________________
Name of investigator (please print)
__________________________________ ________________________
Investigator signature Date

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Psych Assesment Consent Form

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Request to for Clinical Assessment for a Case Study

Study Title: PSYCHOLOGICAL ASSESSMENT

Student Investigators: Jamolin, Joana Margarette F.

Privacy and Confidentiality

For More Information

If you do not give permission, no action is required on your part.

Jamolin, Joana Margarette F.

Study Title: PSYCHOLOGICAL ASSESSMENT

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