Informed Consent and Release of Rights
The psychological report and findings conducted by Shannon D. Mullen, Ph.D. for my, or my spouse’s, candidacy to the Permanent Diaconate program are the exclusive property of the Archdiocese of Atlanta. I understand that I will not be provided with a copy of my psychological report, findings, recommendations, or diagnoses by the Archdiocese of Atlanta or by Dr. Mullen/Mosaic Psychological Services, LLC. I understand that the results of my testing and interview responses are contained in my psychological report given to the Archdiocese of Atlanta for their exclusive use.

I have been advised of the limited confidentiality inherent in this type of evaluation and that a report will be provided to the Archdiocese of Atlanta, which is the referring party. I acknowledge this and agree to participate. The custody of this report is exclusively the domain of the Archdiocese of Atlanta. I understand I will not be provided a copy of this report.

My printed name and signature will indicate my acceptance of the above limits to confidentiality and release of ownership as well as my agreement to participate in the psychological evaluation with Dr. Mullen.
Please Print Your Name Below: *
Date of Birth *

Month Day Year
Signature (Candidate/Spouse) *

Clear
Date *

Month Day Year
**PLEASE NOTE:** You must use your mouse to draw your signature in the box above. Failure to do so will result in the Informed Consent and Release of Rights form not being accepted.
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Informed Consent and Release of Rights