Sexual Addiction (SA) Full Disclosure & Maintenance Exam Intake Form

Sexual Addiction (SA) Full Disclosure & Maintenance Exam Intake Form
This form is STEP 2 in the polygraph exam process. Do not complete this form until you have a confirmed appointment date.

This form is for a Subject taking a Sexual Addiction (SA) Full Diclosure or Maintenance Exam ONLY. This form may not be completed by anyone else other than the person taking the polygraph exam.

This form is compromised of 11 different sections, A-I.

A: Exam Verification

B: Subject's Information

C: Therapist's Information

D: Disclaimers

E: Upload Full Disclosure

F: Question Submission

G: Credibility Assesment

H: Policies & Notices

I: Signature & Form Submission

Depending upon your responses, this form may take anywhere from 15 - 30 minutes to complete.

Section A: Verify Your Exam(s) is Already Scheduled
SECTION A: VERIFY YOUR EXAM

Before completing this form, you should have already scheduled and paid for your exam online during Step 1. Please verify your exam information below.
What is the confirmed date of your scheduled polygraph and/or EyeDetect exam? *

MonthDayYear
This was the date you selected in Step 1 when you booked and paid for your exam online.
What is the time of your polygraph and/or EyeDetect exam?

:HourMinutesAM/PM Option
What type of exam(s) have you scheduled?*
This is the service you paid for when you scheduled your exam online during Step 1.
Are you the person taking the exam?

YesNo

Section B: SUBJECT'S INFORMATION
SECTION B: THE SUBJECT'S IDENTITY VERIFICATION AND INTAKE INFORMATION

The Subject is the person taking the polygraph or EyeDetect exam.
Subject's Full Legal Name*
The Subject is the person taking the exam.
List any nicknames or alias names you have ever used ?*
The Subject is the person taking the exam.
Address
Subject's Primary E-mail address*
Email Validator*
Alternative Emails: List any other email addresses you have to include alias email accounts:*
Subject's Phone Number*
Alternative Phone Numbers: List any alternative phone numbers you have to include any alias phones, burner phones, VOIP, communication Apps or digital only numbers. *
Subject's Date of Birth *

MonthDayYear
The Subject must be at least 16 years of age.
What is your relationship to the reporting party? *
In other words, who are you?
Do you, the Subject, have any medical or mental health conditions that could prevent you from safely and successfully taking a polygraph and/or EyeDetect exam?*

NoYes (Explain in the box below)
If you answered YES, please explain in detail in the box below.
Do you, the Subject, take any medications that could effect the exam?*

NoYes (Explain in the box below)
If you answered YES, please explain in detail in the box below.
Have you ever been arrested or convicted of a crime? If yes, please explain each arrest and charges in the space below.*

NoYes (Explain in the box below)
If you answered YES, please explain in detail in the box below.
Do you, the Subject, understand that you are prohibited from drinking any alcohol or using any recreational drugs for a minimum of 24 hours prior to your exam?*

YesNo
Take Photo: To verify that you, the Subject, are the person filling out this form, please take of yourself. *

Section C: THERAPIST INFORAMTION
SECTION C: THERAPIST INFORMATION
Name of the Therapist Company/Business*
Name of your Therapist*
Therapist phone number*
Therapist email*
example@example.com
Should we email your exam results to your therapist?*

YesNo
Define your "Acting Out Behavior" as determined by your therapist and treatment program?*

Section D: Lie Detector Test Notice and Disclaimer
SECTION D: NOTICE AND DISCLAIMER
Read the statement below and then check the button to acknowledge that you read, understand, accept and consent to the following statement in regards to taking a lie detector test.*

I understand that all polygraph and/or EyeDetect exams conducted by Validate, LLC will cover ONE and ONLY ONE Single, Specific Issue per exam. I understand that all relevant questions asked on any exam by Validate, LLC will be directly related to the ONE Single, Specific issue being tested. I understand that the polygraph examiner and/or EyeDetect proctor will formulate, write and solely determine the specific questions that will be asked on any exam. I understand that 2 to 4 relevant questions may be asked on the polygraph exam. I understand that only 1 relevant question, which will be asked in a variety of different ways, will be asked on the EyeDetect exam. I understand that if I have multiple issues and/or more questions than is already included that I would need to purchase additional services for an additional fee. I understand that polygraph exams and EyeDetect exams may only test facts and specific actions. I understand that polygraph exams and EyeDetect exams may not test feelings, thoughts, emotions, fantasies, desires, wants or future intentions. I understand that all questions on a polygraph exam will be in a yes or no only format. I understand that all questions on the EyeDetect will be in a true or false only format. I understand that Polygraph exams and EyeDetect exams are not 100% accurate and have a variable margin of error. I understand that the Subject takes the examination at his/her own risk and of his/her own free will. I understand, consent and agree to hold harmless and release all liability of any kind against Validate, LLC or its members.

Section F: Question Submission
SECTION F: QUESTION SUBMISSION
QUESTION 1: What is the ONE, single most important direct "Yes or No" or "True or False" question you want ANSWERED more than anything else? *
QUESTION 2: For polygraph's only, what is the SECOND most important direct "Yes or No" question you hope to have answered?
QUESTION 2: For polygraph's only, what is the THIRD most important direct "Yes or No" question you hope to have answered?
Do you confirm that the question(s) you submitted meet the above requirements?*

Yes! I confirm the question(s) I submitted meet the above requirements.

Section G: UPLOAD YOUR FULL DISCLOSURE
SECTION G: UPLOAD YOUR FULL DISCLOSURE
Upload a copy of your full disclosure:

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Section I: Policies & Notices:
SECTION I: POLICIES & NOTICES
Do you understand that you are required to arrive a minimum of 15 minutes prior to your scheduled appointment time to complete paperwork?*

Yes. I understand and I will arrive 15 minutes early to my appointment.
Do you understand that due to back to back appointments, we cannot accommodate clients that arrive more than 15 minutes late and that failure to arrive on time may result in cancellation of services without refund?*

Yes. I understand that if I arrive more than 15 minutes late to my appointment that my services will be cancelled without refund.
Do you understand, agree and consent that our entire facility, to include all interviews, exams and meetings are monitored and video and/or audio recorded?

Yes. I understand and consent that all meetings, interviews and exams with Validate, LLC and its members will be monitored and video and/or audio recorded.
No Weapons Policy: Our policy is that no weapons of any kind are permitted within our facility for any reason unless authorized in advance, in writing by Validate, LLC. Any person caught attempting to bring in a weapon of any kind into our facility will be immediately asked to leave, appointment cancelled without refund and will be reported to the authorities. Do you understand, agree and consent to our No Weapons Policy?

Yes. I understand, agree and consent to the No Weapons Policy. I will not bring in any weapons of any kind for any reason unless I have advanced, written authorization from Validate, LLC.
Digital Device Policy: Our policy is that no digital devices of any kind are permitted within our facility to include, but not limited to: laptops, tablets, smart watches, and/or any other recording or transmitting device of any kind. You may bring in your cell phone but it must remain completely powered off at all times throughout the entire process and will be stored in a container for security purposes until your appointment is completely over. Do you understand, agree and consent to our Digital Device Policy?

Yes. I understand, agree and consent to the Digital Device Policy. I will not bring in any digital devices into the facility.
Release of Liability Statement: I freely and voluntarily agree to be interviewed and to undergo polygraph examination(s) and/or EyeDetect exam(s) by Validate, LLC and its members. I understand and voluntarily agree that the interview is separate and exclusive from the polygraph examination(s) and/or EyeDetect exam(s) itself. I understand, voluntarily agree and consent that the polygraph examiner or EyeDetect proctor may use the information gathered during my interview(s) in any way. I may consult privately with a lawyer at my own expense or, for minors, with my parent(s),prior to the interview(s) and polygraph examination(s). The interview(s) and/or polygraph examination(s) will be terminated at any time I request. All questions to be asked in the polygraph examination(s) will be discussed with the Subject prior to the actual testing. All questions on the EyeDetect exam will not be discussed prior to testing. I hereby authorize and request that employees of Dawn Nash & Triune Investigative Services disclose to any and all information, conclusions, and opinions arising out of or connected with my interview(s) and polygraph examination(s), even though such information. conclusions, and opinions may be unfavorable or may result in adverse consequences to me. I have been advised and understand that polygraph tests and eyedetect tests are not 100% reliable and are not 100% accurate. I assume all risk and liability taking a polygraph exam or eyedetect exam. I hereby release and forever discharge Validate, LLC, its member, Dawn Nash & Triune Investigative Services and their employees, agents, representatives, partners, officers, directors, and their successors from all liability, and from each and every demand, claim, or cause of action existing, or which may hereafter arise, resulting directly or indirectly from the conduct of my interview(s) and/or polygraph examination(s), eyedetect and/or publication, communication or dissemination of any information, conclusions, and opinions arising out of or connected with my interview(s), eyedtect(s) and/or polygraph examination(s). I have carefully read this entire “Release and Waiver of Liability,” I fully understand this statement. By signing below, I acknowledge that I have reviewed and completed this “Waiver and Release of Liability” personally and with enough time to deliberate upon its contents. My agreement to undergo interview(s), eyedetect exam(s) and/or polygraph examination(s) is given without threats, promises of leniency or immunity, reward or favoritism, duress, pressure or force. I believe my cooperation with Validate, LLC Dawn Nash & Triune Investigative Services is in my own best interest. By clicking the dot next to this statement, signing your signature at the bottom of this form and submitting this form you freely and voluntarily agree to all parts of this statement.

Yes. I understand, agree and consent to the Release of Liability Statement.

Section J: Sign & Submit
SECTION J: CONFIRM, SIGN AND SUBMIT
I, the Subject, hereby confirm under any applicable laws, that the statements made by me within this form are the truth, the whole truth and nothing but the truth.
Signature*

Clear
Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Email Validator*
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