Maria Segura

Hello my name is Maria segura im 24 years old and im from a little town called cerro New Mexico i grow up rasing show quality livstock as well as training horses . i moved to texas on january 21st of 2024 do to i wanted to experience other opportunities there was to offer. i started working at Grand prairie animal sevices on march 10th 2024 as a intern and worked my way up to becoming a city staff of april 6th 2025 . my goal is to become a animal control officer i have fell in love with the industry im a hard worker .

• Signing your initials next to a statement below indicates that you have read the statement and fully understand and agree to it. If you are unwilling or unable to initial any of the following statements, or if you have questions that you would like answered prior to proceeding, please stop the evaluation process and notify the front desk.
• I understand that I have been referred for a pre-employment psychological evaluation.
• I have received a conditional offer of employment from the agency where I am seeking employment prior to undergoing this psychological evaluation.
• I understand that the referring agency is responsible for the cost of the evaluation.
• I understand that a licensed psychologist (Dr. Proctor, Dr. Reed, Dr. Clayton, Dr. Falkowski, Dr. Clem, Dr. Mathew) will conduct this evaluation.
• I understand that this psychological evaluation will consist of an interview, psychological testing, and a review of background information, including, if available, polygraph examination and prior psychological evaluation results.
• I understand that the interview portion of the evaluation will include questioning/exploration of my psychological history.
• I understand that the Genetic Information Non-Discrimination Act of 2008 (GINA) prohibits the collection of genetic information, including family medical history, as part of this evaluation. I understand that I will not be asked about my family medical history and that I should not provide this information.
• I understand that this evaluation is for assessment purposes only and that the psychologist who performs the evaluation will not be providing any advice or treatment services.
• I understand that I am not a patient of the psychologist who performs this evaluation.
• I understand that the opinions, conclusions, and recommendations made by the psychologist who performs the evaluation might be contrary to my wishes and adverse to my position with the agency to which I am seeking employment.
• I understand that any information I communicate to the psychologist is NOT confidential or privileged.
• I understand that the evaluation results will be sent in the form of a report to the requesting agency. In the event of an unfavorable result, a copy of the L-3 will be sent to TCOLE if an L-3 is requested for this position.
• I understand that unless prevented by unforeseen circumstances, the report will be submitted within the confines of any reasonable timeframe permitted.
• I understand that the requesting agency is the only entity that will receive a copy of the report, and that I will not receive a copy myself. I understand that if I wish to know the findings of this evaluation, I will need to contact the requesting agency to receive that information.
• I understand that if during the course of the interview I provide information that suggests child, disabled, or elderly person abuse that has not been previously investigated, or any other information that requires mandatory reporting, the psychologist will report this information to the appropriate authorities.
• I understand that I may take a break or discontinue the evaluation at any time.
• I understand that due to varying circumstances that could prevent a face-to-face evaluation, the clinical interview or entire psychological evaluation may be conducted via two-way interactive video conferencing (i.e., telepsychology).
• I understand that the psychologist may conduct this evaluation at a different location than me.
• I understand that, if my evaluation is conducted via telepsychology, I agree to be located in a private, quiet, distraction-free space during the evaluation.
• I agree that, if my evaluation is conducted via telepsychology, there will not be any other individuals present during the evaluation. This includes that there will not be anyone else in the room with the psychologist nor in the room with me. In addition, there will not be anyone else present on the video conference without consent from both parties.
• I agree to confirm my identity and that I am alone at the start of the evaluation.
• I understand that, if my evaluation is conducted via telepsychology, I agree to provide my phone number and/or address where I can be contacted and/or located during the evaluation in the event of technical issues or a crisis situation.
• I understand that, if my evaluation is conducted via telepsychology, I agree to use a webcam with a secure internet connection (i.e., not cellular data or public WiFi).
• I understand that the psychologist conducting the evaluation will not record any portion of the evaluation whether the evaluation occurs face-to-face or via telepsychology.
• I agree that I will not record any portion of the evaluation, whether conducted face-to-face or via telepsychology. This includes that I agree not to use screen recording software, take screenshots, or reproduce any of the test materials used during the evaluation.
• I understand that, if my evaluation is conducted via telepsychology, standard administration of psychological tests will be modified, which has the potential to affect test results to some degree.
• I understand that the psychologist conducting the evaluation will determine whether telepsychology may not be appropriate and alternative assessment procedures may be utilized.
• If you fully understand and agree to all of the statements on this consent form and wish to go forward with the evaluation process, please sign and date below.
• Printed Name
• Signature
• Name of Requesting Agency
• Date
• Revised 9-2024