IDesILaytagsp 13373331641l Q7UV( NO}jQ   4 G0rU  8O &,28>DJPV\bhntz6 k g`FE00$v6NSubmit 6x $+4<5H6f76069503821609045I64BGG_6j~@@ 6xthisTITIT pr$ 1337333164154%. BlV "u D'0'V " propalis 8 propalisB Helvetica*0@1 Times@>as,as,rV{rr@>@04*Geneva`@@wwwwww  `XD d6 T.>0< 0N_! ` P$ P  ? $  @  o !  p ` `     O   P.P. 0 %DSHS 20-205 (REV. 02/2004) TRANSLATED0@! \*JUVENILE REHABILITATION ADMINISTRATION (JRA) INFORMED CONSENT FOR PLETHYSMOGRAPH EXAMINATION ,  .0$ +.0@@,P n d+,Q WITNESS *#+.0$ @@,P n e+,Q$ DATE *P@@ n f`p  CLIENT'S NAME *<P@@ n h`  JRA NUMBER *6(+@@*@ n k)*A >PARENT/LEGAL GUARDIAN SIGNATURE SIGNATURE REQUIRED IF CLIENT IS LESS THAN 18 YEARS OF AGE F  (+$ @@) n l))$ DATE *@@# The purpose of this plethysmograph examination has been explained to me. I understand such examinations can be utilized to infer useful information about my current sexual arousal pattern, which can assist counselors in making decisions about my current course of treatment. I have been told the results of this examination cannot be used to assess guilt or innocence for alleged sexual misconduct.  ZZ%n< Z%<n 8 %n<,Arial (0/pThe purpose of this plethysmograph examination has been explained to me. I understand such examinations can be (@/tutilized to infer useful information about my current sexual arousal pattern, which can assist counselors in making (P/tdecisions about my current course of treatment. I have been told the results of this examination cannot be used to (`/8assess guilt or innocence for alleged sexual misconduct.P@@ n m`  DATE OF BIRTH *<P$ @@ n n`$ SCHEDULED EXAMINATION DATE *&P($ @@ ' n o&`'$ DATE *&P(@@ ' n p&`' CLIENT SIGNATURE *L## I understand this examination involves listening to audio tapes describing people engaging in a variety of deviant and non-deviant forms of sexual behavior. I understand I will be asked to wear a gauge type of instrument that will measure penile tumescence (erections) as I listen to these tapes. I have been told I will have complete privacy throughout this examination, and I will not be viewed in any state of undress by the examiner at any time during this procedure. I understand plethysmograph examinations can create some anxiety and/or embarrassment, but I have been assured that they are not physically uncomfortable or dangerous in any way. I have been told this procedure is completely voluntary, and I do not have to go through it unless I feel it will be helpful to my treatment. I understand I can choose to stop this procedure at any time, for any reason, and the examiner will discontinue testing at my request. I have been told there are other ways to obtain information about my sexual interests (such as clinical interviews, tests, and questionnaires) in the event I elect not to participate in this procedure. I understand this examination will result in a written report, which will be shared with my primary counselor and other treatment staff involved in making treatment decisions on my behalf. This report will then be placed in my case file and become part of my official case record.  `%D< %`<D 8 `%D<,Arial (v/wI understand this examination involves listening to audio tapes describing people engaging in a variety of deviant and (/qnon-deviant forms of sexual behavior. I understand I will be asked to wear a gauge type of instrument that will (/qmeasure penile tumescence (erections) as I listen to these tapes. I have been told I will have complete privacy (/vthroughout this examination, and I will not be viewed in any state of undress by the examiner at any time during this (/nprocedure. I understand plethysmograph examinations can create some anxiety and/or embarrassment, but I have (/ubeen assured that they are not physically uncomfortable or dangerous in any way. I have been told this procedure is (/{completely voluntary, and I do not have to go through it unless I feel it will be helpful to my treatment. I understand I (/ocan choose to stop this procedure at any time, for any reason, and the examiner will discontinue testing at my (/rrequest. I have been told there are other ways to obtain information about my sexual interests (such as clinical (/uinterviews, tests, and questionnaires) in the event I elect not to participate in this procedure. I understand this (/vexamination will result in a written report, which will be shared with my primary counselor and other treatment staff (&/vinvolved in making treatment decisions on my behalf. This report will then be placed in my case file and become part (6/of my official case record.#%# I have had the above explained to me, and have had the opportunity to ask questions and get clarification regarding all of the information on this form. I hereby consent to this examination.  \\5%i< \%5<i `%D< 5%i<,Arial (L/jI have had the above explained to me, and have had the opportunity to ask questions and get clarification (\/Uregarding all of the information on this form. I hereby consent to this examination.@ @  the examiner will discontinue testing at my(/qrequest. I have been told there are other ways to obtain information about my sexual interests (such as clinical(/tinterviews, tests, and questionnaires) in the event I elect not to participate in this procedure. I understand this(/vexamination will result in a written reports, which will be shared with my primary counselor and other treatment staff(&/uinvolved in making treatment decisions on my behalf. This report will then be placed in my case file and become part(6/of my official case record.#%#  fI have had the above explained to me, and have had the opportunity to ask questions and get clarification regarding all of the information on this form. I hereby consent to this examination.     FF5%h< %5<h  5%h<,Arial (L/iI have had the above explained to me, and have had the opportunity to ask questions and get clarification(\/Uregarding all of the information on this form. I hereby consent to this examination.consent to this examination.     jj5%h< %5<h  5%h<,Arial U(L/iI have had the above explained to me, and have had the opportunity to ask questions and get clarification(\/Uregarding all of the information on this form. I hereby consent to this examination. had the opportunity to ask questions and get clarification(\/Uregarding all of the information on this form. I hereby consent to this examination.` ?`0?`?p00001`98 ?0~` ~ @  p@  0@? ?0@ 1@   > 1 0?    ?|8?         $0#drBlack2P<*STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES   ./@d2Black2P!DSHS 20-203 (08/93) TRANSLATED   P"`drBlack2PPOLYGRAPH INFORMED CONSENT   *!dPBlack(*dBlackCell1@@ddd(1 ddn Hn/.d((dmBlack22WITNESS(*!dY"BlackCell2Nddd(1 ddn Hn/.e((!d2Black22DATE"%`dNBlackCell3Nddd#1 ddn Hn/.f"#d2Black22 YOUTH'S NAME"%`!dNBlackCell5Nddd#1 ddn Hn/.h"#!d2Black22 DJR NUMBER%`(dNBlackCell4 <Nddd& 1 ddn Hn/.k%p&AdBlack22YOUTH'S SIGNATURE%`(!dNBlackCell8Nddd& 1 ddn Hn/.l%p&A!d2Black22DATE 0dBlack2P)DIVISION OF JUVENILE REHABILITATION (DJR)- -d2Black2P?*DISTRIBUTION: White - Case File Yellow - Working File @dBlack2P3The purpose of this polygraph examination has been explained to me. I have also been informed that Washington State Law (RCW 26.44.030) requires that any previously unreported disclosures of abuse and/or neglect must be reported to Child Protective Services and/or the appropriate law enforcement agencies.  + ,0d2Black2P Attachment A DJR Bulletin No. 31  etin No. 31  ll4 <Nddd#1 ddn Hn/.k"#d2Black22YOUTH'S SIGNATURE"%`!dNBlackCell8Nddd#1 ddn Hn/.l"#!d2Black22DATE 0dBlack2P)DIVISION OF JUVENILE REHABILITATION (DJR)-P -d2Black2P?*DISTRIBUTION: White - Case File Yellow - Working File FFFFFFFFFFFFFFFFFFFFFF FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF 000FFFFFFFFFFFFC003F800780078007FFFFFFFFC003FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFB 000FFFFFFFFFFFFE003F800780078007FFFFFFFFC003FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFD 001FFFFFFFFFFFFE007F80078007800FFFFFFFFFC003FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFC 001FFFFFFFFFFFFF00FFC00FC00FC00FFFFFFFFFE007FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFV*3Submit >N6XXjdVXXd'@Lʜ r?d[OrO= @$@ @ "$DI'2I'2DI'2I'2I'2I'2I'2 propalis propalisN propalisH propalisB porpsila* porpsila6<EDArialO RomanQ72GhQbSS ?I@@@@% n @@ >X       R @@/< P @@ >X       R @@@@%  @@ >X       Rj  VQ73Submit (U(z(z $ ?  ?    ?  ? ? ?@ G3? 10 18 1~ 0w  D0c  D0`Cp  $0`C0? ? 0`F0? 00`1 00`0 >0`?0`p 00`0p00 À?000p 0 ? 0 0 8 |@88@~x @|! 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