Informed Consent and Release of Rights
Minor's Name *

First Name Last Name
Minor's Date of Birth *

Month Day Year
The psychological report and findings conducted by Shannon D. Mullen, Ph.D. for my minor child’s candidacy to the seminary program of the Diocese of Dallas, TX are the exclusive property of the Diocese of Dallas. I understand that I will not be provided with a copy of my son’s psychological report, findings, recommendations, or diagnoses by the Diocese of Dallas or by Dr. Mullen/Mosaic Psychological Services, LLC. I understand that the results of my son’s testing and interview responses are contained in his psychological report given to the Diocese of Dallas 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 Diocese of Dallas, which is the referring party. I acknowledge this and agree to allow my son to participate. The custody of this report is exclusively the domain of the Diocese of Dallas. I understand I will not be provided a copy of this report.

My signature as the legal guardian indicates my acceptance of the above limits to confidentiality and release of ownership as well as my agreement to allow my child to participate in the psychological evaluation with Dr. Mullen.
Please Print the Legal Guardian's Name Below: *
Signature of the Guardian *

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Date *

Month Day Year
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Informed Consent and Release of Rights