INFORMED CONSENT

I_____________________________________________ authorize and request that Talin Hovsepian, Psy.D.

administer Personality Assessment Inventory. My birth date is _____________________. By initializing each
item below, I indicate that I have read it carefully, understand it, and agree to it. If I have questions about this
screening, I know to discuss them with Dr. Hovsepian.

______1. I understand that Dr. Hovsepian is administering a personality assessment and clinical interview only as
partial requirement for my participation as a client with Fertility Miracles.

______2. I understand that I am not authorized to record the screening appointment. I also understand that I am
required to keep the details of the screening process and/or questions ask confidential. I am not to have another
person observe the screening session.

______3. I understand that all information revealed during this screening will be included in a report to be
submitted to Fertility Miracles.

______4. I understand that Dr. Hovsepian will write a report that summarizes the findings of this screening and
send it directly to Fertility Miracles.

______5. I understand that Dr. Hovsepian will not be providing me with the results of this screening or a copy of
the report. I also understand that the results or report from this screening cannot be shared with a third party.

______6. I understand that if I disclose certain types of information to Dr. Hovsepian she may be required by law to
communicate this information to other individuals. Types of information that can mandate or allow a breach of
confidentiality include reports of child or elder physical, sexual or emotional abuse, and threats I make to harm
myself or harm another person.

______7. In the event that electronic communication was used during this assessment, I understand and agree to
limits of confidentiality that this mode of communication can present.

CONSENT AGREEMENT: I have read, understood, and agreed to each of the previous items. I have asked
questions about any part(s) I did not understand. I understand and agree to the nature and purpose of this screening,
how it will be reported, and to each of the points enumerated above.

______________________________________________________________________________________________________

Print Name Signature Date

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Address Phone Number

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Email Address

5016 Parkway Calabasas, Suite 220, Calabasas, CA 91302 • fultonpsychologicalgroup.com • (818) 591­3000