4-6 pages Adolescent Psychology Imterview

Confidentiality: All information gathered in this interview will be held confidential and used merely for the purpose of completing the course requirements. Each questionnaire will be given a false name, only to protect confidentiality. No one other than the interviewer and the instructor will have access to the content of the interview.

Parent: I have read the above and understand the conditions outlined for participation in the described interview I give informed consent for my child, _________________, to participate in this interview.

Adolescent: I, ___________________, have read the above and understand the conditions outlined for participation in the described interview.

Student’s Name: _________________________________ Date: _________

Student Age: ______ Student Grade: _____ Student Gender (circle one): M F

Parent/Guardian’s Name:____________________

Parent/Guardian Signature: _____________________

Student’s Signature: __________________________