Informed Consent - Adult version

CONSENT FOR PARTICIPATION IN RESEARCH - ADULT

I give permission to Dr. Faedda and his associates to use for research purposes the following:
• Neuropsychological and/or Psychological testing reports;
• Questionnaires included in the “Active Surveys” package;
• MoodLog™ records and other Rating Scales data and scores;
• Information obtained during clinical interviews/treatment sessions;
• Data from other professionals involved in my care.
• Activity Monitoring data;

1. I am aware that all records and information are confidential and will be treated anonymously.
2. The data collected belongs to the principal investigator, Dr. Gianni Faedda.
3. My participation is voluntary, and can be revoked at any time by simply notifying the doctor.
4. My treatment will not be affected by a decision to participate or not to participate in this research.
5. There are no risks involved in my participation in this project, other than possible loss of confidential information.
6. The benefits to me include an in depth evaluation of certain aspects of my illness with potential benefits to my current and future treatment.

Thank you for your participation,

Gianni Faedda

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Sign, print name and date

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Gianni L. Faedda, M.D.

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Date

This document has to be provided in original form. Please mail your signed and dated copy to the Center.
You can request a copy after it has been filed in our system. Thank you for your cooperation.