MCMI Consent Form

Please complete the consent and preliminary information below so our team can review your submission before sending your MCMI assessment link.

Name

This field is for validation purposes and should be left unchanged.

Participant Information

Enter the information of the person taking the assessment.

Name(Required)

First Last

Phone(Required)

Email(Required)

Date of Birth(Required)

Gender(Required)

Race/Ethnicity(Required)

Marital Status(Required)

Please specify your marital status.(Required)

Select your highest education level(Required)

Please specify your education level(Required)

Preliminary Information

Select your primary concern, secondary concern, and how long you’ve experienced these concerns.

Primary Problem(Required)

Select the issue that is causing you the most difficulty or is your main reason for seeking this assessment. This is your number 1 concern.

Please specify your other primary problem(Required)

Secondary Problem(Required)

Select another issue that is affecting you, but is less significant than your primary concern. This is your number 2 concern and should be different from your first selection.

Please specify your other secondary problem(Required)

Duration of Clinical Syndrome Episode(Required)

How long have you been experiencing the symptoms or problems that led you to seek this assessment? Select the option that best describes their duration.

Current Therapist

Current Therapist’s Name(Required)

First Last

Therapist’s Phone(Required)

Therapist’s Email Address(Required)

Informed Consent and Signature

Please read the consent below before agreeing and signing.

MCMI Informed Consent and Release of Information(Required)

1. Introduction

The MCMI is a psychological assessment used to provide insights into a patient’s personality, particularly as it relates to personality disorders outlined in the DSM. It’s designed for adults (18+) seeking mental health treatment and is used for diagnostic screening and clinical assessment.

2. Description of the MCMI Test

The assessment will be emailed to you to complete all questions in entirety.

Estimated time required to complete the test is about 45 minutes.

You must answer all questions emailed to you before we send you the online inventory.

You must be in a distraction free environment, not use the help of any websites to answer questions.

You agree to the following:
- Video of the assessment should not be captured.
- Photos should not be taken.
- Stimuli should not be copied or recorded, as this is a copyright violation.
- You must agree that you will not record (audio or visual) or take photos or screenshots of any portion of the test materials or testing session, and not permit anyone to observe the testing session or be in the testing room (except for a facilitator, when necessary).

3. Purpose of the Evaluation

The reason for administering the MCMI test is part of a psychological evaluation in which you must be under the care of a licensed clinician and give us permission to share the results with your current clinician for ongoing treatment. Test results will be used to inform diagnosis and treatment planning.

4. Confidentiality

Your information will be protected and kept confidential to the extent allowed by law and professional ethics.

A testing results summary will be given to the participant and/or clinician as deemed appropriate by the facilitator. We do not release the MCMI outside of this office, and a summary will be issued upon request.

Rock Your Family LLC will have access to the test results to include the facilitating clinician.

As with all counseling services, we are mandatory reporters and should it become known during the course of the assessment and treatment that there is a matter that falls under mandatory reporting, we would adhere to all legal and ethical laws and requirements.

5. Benefits and Risks

Potential benefits of the MCMI testing are improved understanding of personality and symptoms, and more targeted treatment.

Potential risks can include emotional distress from answering personal questions, potential for misinterpretation of results and other risks associated with counseling and treatment.

6. Right to Refuse or Withdraw

You verify your participation is voluntary and you have the right to refuse to take the test or withdraw from the testing process at any time without penalty. You will however still be due for the cost of the test if it has already been purchased as no refund is given for that amount.

7. Opportunity to Ask Questions

You have the right to ask questions and receive clarification about the testing process before signing the consent form. You will have a questionnaire before the testing is ordered to ensure you are within the clinical guidelines to complete the testing to include signing a release of information form to your current therapist.

8. Release of Information

You agree to a verbal consultation and written release of information (ROI) for the named person overseeing your treatment to include but not limited to your contact information, testing results, and interpretive analysis.

I have read, understand, and agree to the above terms and conditions.

Signature(Required)