• Consent For Fitness For Duty Evaluation & Release Information

  • I,       consent to and authorize Mark E. Oakley, PhD to conduct a psychological evaluation including a fitness for duty evaluation, an interview, psychological testing and review of information at the request of   *    (Employer) on   Pick a Date   

  • I understand that Dr. Oakley has been retained by an is acting at the request of my Employer, * , and that Dr. Oakley will provide the results of the evaluation to my employer. These results may be provided in writing and/or verbally and may include the following: an evaluation and assessment of my psychological and emotional status including a determination of my fitness for duty and or a description of any functional limitations.

  • I understand that in addition to the above, Dr. Oakley is required or permitted to disclose information in the following circumstances:

    • If Dr. Oakley has a reasonable suspicion of child abuse or abuse to a dependent or elder adult.
    • If I communicate a serious threat of bodily injury to an identifiable victim or if Dr. Oakley has a reasonable belief that I may be a danger to myself, another or the property of another.
    • As required pursuant to a legal proceeding or as otherwise required by law.

  • I understand that while Dr. Oakley may make recommendations regarding my
    treatment as a result of my evaluation, that Dr. Oakley will assume no
    role in my treatment and that he will not provide psychological
    counseling or follow-up services to me. I understand that there is no
    psychotherapist-patient relationship between Dr. Oakley and myself. I
    understand that this consent is non-revocable and that my refusal to
    cooperate may result in the delay of my return to work status. I
    understand that I have the right to receive a copy of this
    authorization. This authorization shall become effective on   Pick a Date   and will expire in one year. A photocopy or facsimile of this form is to be considered as valid as the original.

    I HAVE RED THIS CONSENT FORM IN ITS ENTIRETY AND FULLY UNDERSTAND ITS CONTENTS. I HAVE HAD THE OPPORTUNITY TO RECEIVE CLARIFICATION. I CONSENT AND AGREE TO THE ABOVE TERMS AND CONDITIONS.

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