Compensation & Pension Evaluation Consent Form [This is NOT a Department of Veterans Affairs (VA) form.] I understand that... 1. I filed a claim with the VA indicating that I suffer from a mental disorder, which causes noticeable social and occupational impairment. 2. Today I will receive a psychological evaluation from ______________, a [clinical psychologist] [board-certified psychiatrist]. The purpose of this evaluation is to provide the Veterans Benefits Administration (VBA), which is part of the VA, with information they need to make a decision regarding my claim for Compensation & Pension (C&P) benefits. 3. I am not a patient or client of Dr. _____. I will not be receiving [counseling or psychotherapy] [psychiatric treatment] from Dr. _____. The only reason for this visit is to conduct a [psychological] [psychiatric] evaluation for Compensation & Pension (C&P) purposes. 4. If I want to receive mental health treatment from the VA, I can call any VA medical center or clinic to request an appointment or a referral to a doctor or counselor in my community. In many instances I can talk with a VA psychologist, psychiatrist, or other mental health professional for free or a low co-pay. [Check with the Eligibility Office at your VA medical center or at https://www.va.gov/health-care/about-va-health-benefits/ ] 5. [It is a federal crime to possess weapons (e.g., guns; knives over 2 1/2 inches long) on VA property.] 6. This evaluation and its contents are private and confidential except under the following circumstances: (a.) If I am in imminent danger of harming myself or another person, Dr. _____ must take whatever steps necessary to prevent harm and this might mean breaking confidentiality. (b) If I share information that would lead a reasonable person to suspect that a child or disabled adult is being abused or neglected then Dr. _____ must report that information to Protective Services. {Important: You might need to phrase this differently depending on the jurisdiction.} (c) If I threaten to harm Dr. _____ [or any VA employee] or his/her/their family members, now or in the future, Dr. _____ will immediately notify [the VA Police], the FBI, [VAOIG agents], and [local law enforcement]. 7. Dr. _____ will write an evaluation report and send it to [the VBA Regional Office that is handling my claim] [MDE company]. Dr. _____ cannot give me a copy of the exam report. I must request the exam report from VBA. If I have a veterans service officer, they can help me. 8. I must be honest in answering questions on all psychological questionnaires, tests, and interviews during this evaluation. Any attempt to exaggerate or fabricate symptoms of mental disorders or associated problems could have negative consequences for my claim. 9. This evaluation might be stressful for me. I might feel upset (sad, anxious, irritable, overwhelmed, panic, depressed, etc.) as a result of answering questions during this evaluation. I may take a break at any time during the exam. 10. Initial PTSD exams only - Dr. _____ must document one or more traumatic stressors that I believe caused me to develop posttraumatic stress disorder. I do not need to tell Dr. _____ every single detail-just a general description of what happened and how it affected me. Dr. _____ might need to ask some follow-up questions, but, in general, he/she/they intends for this part of the interview to be relatively brief and to the point. (This does not mean that he/she/they will rush me- he/she/they won't. And if I need to describe what happened in a fair amount of detail, for whatever reason, that is fine too.) 11. Dr. _____ has given me the Veterans Crisis Line phone number (1-800-273-8255), which I can call if I feel suicidal or overwhelmed. 12. Review exams for an increase and/or Individual Unemployability only - If I filed a claim requesting an increase in my rating for a service-connected mental disorder, I understand that the VBA will review all the relevant evidence, including the results of this exam, and will then increase, keep the same, or decrease my disability rating. Thus, even though I requested an increase, if the VBA determines that I have less social and occupational impairment as a result of my service-connected mental disorder than I had at the time of my last rating, they might decrease my rating. This does not happen very often, but it is possible. 13. I am entitled to Travel Pay for this appointment, even if I am not currently service-connected. [Go to the Travel Office before you leave to receive your payment.] (This does not apply to IDES exams, or if I was transported here by a DAV van or other complimentary service.) 14. If I had any questions about this consent form, I have asked them and Dr. _____ has answered them to my satisfaction. PRINT Name: __________________________________________________________ Sign Name: ___________________________________________________________ Today's Date: ________________________________ SAMPLE Informed Consent Form | Mark D Worthen PsyD | www.PTSDexams.net | July 2020 | Page 1 of 2 This is NOT a Department of Veterans Affairs (VA) form.