Exhibit C. Sample Pediatric Forensic Informed Consent Form (Longer Version) {Insert Letterhead} INFORMED CONSENT FOR NEUROPSYCHOLOGICAL ASSESSMENT {insert attorney or other retaining party}, has referred your child, {insert child s name}, for an independent neuropsychological assessment by Dr. Smith, a psychologist registered in the state of California (Reg.# ). Apart from providing independent assessments, Dr. Smith is not in any way associated with this law firm. What is a Neuropsychological Assessment? Neuropsychological assessment is a process for evaluating cognitive functions, such as intelligence, problem solving, language, attention, learning and memory. Emotional adjustment and life stress are also evaluated. No invasive procedures are involved and the examination will not be physically painful. The products of the assessment include Dr. Smith s professional opinions about: The nature, extent, causes and outcome of any brain injury or brain dysfunction that your child may have The nature, extent, causes and impact of any emotional/adjustment problems that your child may have The nature and extent of any factors that may impact on the validity of the assessment, such as poor effort Why has a Neuropsychological Assessment been requested? This assessment is meant to inform parties involved in an existing or potential civil legal proceeding, and is not being carried out for any other purpose. Consequently, Dr. Smith will
not provide your child with any psychological treatment or care and will not discuss any aspect of diagnosis or treatment with your family. Dr. Smith will not discuss any aspect of any legal proceeding with your family except as necessary for conducting this assessment. Normally, Dr. Smith will not be in direct contact with your family after s/he has completed the assessment. Please refer any questions or comments that your family may have after the assessment to your lawyer. What will happen during the assessment? Dr. Smith s assessments typically take two days. The assessments normally include: Interviews with you and possibly other people who know your child (e.g., teacher) Questionnaires completed by you and possibly other people who know your child (e.g., teacher) Observations of your child s behaviour during the assessment Tests of cognitive functions such as intelligence, problem solving ability, language, attention, learning and memory Measures of your child s emotional state and level of psychological adjustment Dr. Smith will also review all available records (e.g., medical, legal, educational). What is my role and my child s role in the evaluation? You and your child must answer truthfully and completely to any questions asked by Dr. Smith. You must respond honestly to all questionnaires. Dr. Smith will report any significant differences between what you or your child reported and what others say or have said or written about your child. What happens after the assessment is completed? Dr. Smith will usually write a report that includes:
A description of any particular cognitive or emotional problems that your child may have Dr. Smith s opinion about what may have caused any cognitive or emotional problems that your child may have The report may include other types of opinions or recommendations if these are requested by the referring party. Who will receive copies of Dr. Smith s report? The report will be sent to {insert attorney or other retaining party}. The report may also be shared with other parties involved in your child s court case such as the opposing lawyers and their assistants, officers of the court, judges, or juries. The results of the assessment may also become part of the public legal record. Dr. Smith will not convey the results of his or her assessment directly to your family. Please consult with your lawyer if you want to know the results of this assessment. If one of your child s health care providers requires a copy of Dr. Smith s report, you should arrange to have a copy sent by your lawyer. In what other ways will information on my child be shared? Dr. Smith may discuss his or her findings or any other information obtained during the assessment with {insert attorney or other retaining party}. Dr. Smith may also be required to give a deposition or testify in court regarding this assessment. In accordance with legal and ethical standards of psychological practice, Dr. Smith may share his or her report or other information obtained during this assessment with persons who are not parties to your child s court case (e.g., police) if: Your child s statements or behaviour or your statements or behaviour suggest that a he/she or another child may be abused, neglected, or otherwise harmed Your child s statements or behaviour suggest that your child is likely to harm him/herself
or someone else A judge hearing a different court case orders Dr. Smith to turn over records or orders and have him/her testify about your child In these cases, information about your child that is relevant to the specific concern will be shared with authorities and others as required by law or as necessary to protect those who may need it. What are the possible consequences of my child s participation in this assessment? Your child s participation in the assessment may lead to significant consequences. The results of this assessment may not support your child s litigation. The results of this assessment may become publicly available if it is presented in court. Is my child s participation in this assessment voluntary? You and your child have the right to refuse to participate in this assessment. Your child may also stop participating in the assessment at any time. Do not sign below if you do not understand any part of this document or do not agree to any part of this document. I,, by signing below, give my full and informed consent to have my child participate in a neuropsychological assessment conducted by Dr. Smith as described above. My initials above indicate that I have read and understand the meaning of each corresponding section, and that any questions I had about this assessment have been explained to my satisfaction. By signing below, I authorize Dr. Smith to send a report of this assessment to the law corporation {insert attorney or other retaining party} and to discuss
the assessment with them as needed. I understand that I am entitled to have a copy of this consent form. Signed Date Witness Date This assessment took place at the offices of: _ I have received a copy of this consent form