I, client name*, agree to participate in a psychological evaluation / intervention which may include interview, psychological testing, or therapy.

I am aware that the process may be audiotaped or videotaped and observed by two or three psychologists who will be evaluating the interviewer.

I understand that the interviewer/therapist will be a graduate student in the Doctor of Clinical Psychology Program at Wheaton College.

I further understand that the observers will keep all information revealed in the course of
the evaluation confidential.

I understand all copies of the recording(s) will be destroyed by the Psychology Department
subsequent to the student’s examination.

I recognize that participation in the examination procedure is not a requirement to receive treatment at training site name*.

My participation is completely voluntary.

I may withdraw this consent at any time.

This will automatically expire three years from the date it is signed.