I __________________ whose signature appears below agree to participate in

this interview/ case study and cognitive assessment/testing to be conducted by

Novely Durias (the researcher) who is currently enrolled at the BS Psychology

Program of the Holy Cross of Davao College as a part of the requirement in the Psy

7 (Psychological Assessment and Testing). The purpose of the study/ research has

been explained to me as well as my rights as participant. Part of which is my right to

withdraw my76 participation anytime during the course of the study/research or

whenever I feel that my right has been or is being violated.

Signed this ___ day of _____________, 201__.

Signature________________

Research Participant