GMF Program Forms

ACKNOWLEDGEMENT OF THE LIMITS OF CONFIDENTIALITY

AND

CONSENT FOR DISCLOSURE OF INFORMATION

I, ________________________________________, agree to unrestricted communication between John Petty, Psy.D. and the attorney, organization, state or federal agency referring me; and where relevant, the Court involved in my sentencing and/or supervision.

I understand that the purpose of this waiver is to coordinate evaluation services and making the results of such services available to concerned parties involved in any legal disposition of my behaviors.

I also understand that Green Mountain Forensics is obligated under Vermont law to report acts of abuse towards children under the age of 16, the disabled, or the elderly.  I also understand that Dr. Petty has an ethical and professional responsibility to inform the authorities or others, if in Dr. Petty’s professional opinion, my behavior presents a clear and immediate danger to myself or others.

I understand that I may retract this waiver at any time, except to the extent that Dr. Petty has already acted in reliance on it. This waiver will expire 60 days from the completion of the written evaluation report.

I have had this consent fully explained to me by Dr. Petty, fully understand it, and give my consent.

Signed:_________________________________________________________

Date:________________

I have fully explained this consent to the above named person and he has said that he fully understands it and consents. I have witnessed his signature above so indicating.

_______________________________________________________________

Date:________________

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FORENSIC INFORMED CONSENT CONTRACT

This Forensic Psychological Evaluation is being conducted at the request of ______________________________________________ and is therefore somewhat different than other psychological services.  It is important for you to understand how a forensic evaluation differs from more traditional psychological evaluations.

While the results of this evaluation may or may not be helpful to you personally, the goal of this evaluation is to provide information about how you are functioning psychologically to the individual or agency requesting the evaluation.

In most cases, this evaluation is intended for use in some type of a legal proceeding.  As such, the confidentiality of the evaluation and the results is determined by the rules of that legal system.  If your attorney has requested this evaluation, he/she will receive a copy of my report and will control how it is to be used and who has access to it.

Normally, the results of this evaluation are protected by the attorney-client privilege.  Exceptions to this might include a determination on my part that you are dangerous to another person or if you reveal information that a child under the age of 16 has been abused.  I would also have to release this information if a court orders me to do so.  There may be other examples where the laws require me to release the information obtained during the evaluation. We will discuss these situations on a case-by-case basis.

Once a decision has been made to use the report in a legal proceeding, the report and any information pertaining to it will probably be admissible into evidence as well as any other information that was provided concerning your mental health and functioning.  If you have any concerns about the use or distribution of my report, you should discuss these issues carefully with your attorney.

If someone other than your attorney requested the evaluation, that individual is my client and he/she has complete authority over the results, including whether or not any information will be released to you or to anyone else. In addition, because the evaluation was requested by another party, and is not for the purpose of treatment or counseling, the confidentiality may have fewer legal protections.  I will not release the information unless instructed to do so by the person or entity that hired me or when I am legally required to do so.

Your participation in this evaluation is voluntary.  I will not conduct the evaluation without your signature on this document.  You also have the right to stop the evaluation at any time.  There may be legal consequences if you stop the evaluation; therefore, it would be in your best interest to consult with an attorney before doing so.

You understand that this is an agreement for evaluation only. You understand that Dr. Petty does not have a duty or obligation to represent you in a court of law regarding this evaluation. Where pertinent, a future court appearance may require an additional agreement and an additional fee.

You understand that your evaluation may include any or all of the following evaluation components:

  1. Background Information – You understand that the referring individual or agency has arranged to have relevant records (e.g. psychological evaluations, major hospitalization records, victim statements, police affidavits, etc.) forwarded to Green Mountain Forensics so that they may be reviewed before your evaluation. You understand that you may be asked to sign releases to obtain other information about your history and that Dr. Petty may want to interview other individuals relevant to your case.
  2. Psychological Testing – During this portion of the evaluation you will be asked to complete paper-and-pencil tests that will assess such areas as your personality characteristics, intellectual abilities, and sexual knowledge, attitudes, and behavior. This portion of the evaluation typically takes two to three hours. you understand that if you have difficulty reading, test items will be read to you. Should this be necessary, you understand the evaluation may have to be extended to one or more additional appointments and that additional charges will be incurred.
  3. Clinical Interview – During this portion of the evaluation you will be asked to discuss important events that have occurred during your life. You will be asked questions about your parents, educational background, hobbies, sexual development, substance abuse, and other topics. This portion of the evaluation typically takes two to three hours.
  4. Risk Assessment Instruments – Your risk for sexual, nonsexual violent, and/or general criminal recidivism may be assessed using several actuarial risk instruments. The use of actuarial risk instruments has been found to be moderately more accurate in predicting recidivism than clinical opinion. It is important to recognize that it is not possible to predict which specific individual will reoffend. The person’s score on a risk instrument puts him in a pool of risk with other individuals having similar scores. Individuals with similar scores are then followed for a period, and the recidivism risk for that pool is then determined based upon new charges or convictions. As risk instrument scores increase, the likelihood of recidivism within the pool increases. The risk instruments are scored during the writing of the report.

If, at any time, you have a question about any aspect of the evaluation or these procedures, pleased feel free to ask me.  In addition, if at any time, you need a break from the evaluation, please let me know and we will stop. Once the evaluation is completed, and with the permission of the requesting party, I may be able to have a meeting with you to explain the results and answer any questions you might have.

I/We understand and accept this evaluation agreement.

__________________________________________________________________

Signature of Client                                                                           Date

__________________________________________________________________

Signature of Parent, Guardian, or Legal Representative          Date

__________________________________________________________________

Witness to Signature(s)                                                                    Date

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Vermont Mandated Disclosures

Vermont law requires mental health professionals to disclose to each client his or her professional qualifications and experience, those actions that constitute unprofessional conduct, and the method for filing a complaint or making a consumer inquiry. This must be done by the third appointment.

The Vermont Secretary of State, Office of Professional Regulation provides Vermont licenses, certifications, and registrations for over 56,000 practitioners and businesses. Forty-six professions and occupations are supported and managed by the office.

Each profession or occupation is governed by laws defining professional conduct. Consumers who have inquiries or wish to obtain a form to register a complaint may do so by calling (802) 828-2875, or by writing to the Director of the Office, Secretary of State’s Office, 89 Main Street 3rd Floor, Montpelier, Vermont 05620-3402.

Upon receipt of a complaint, an administrative review determines if the issues raised are covered by the applicable professional conduct statute. If so, a committee is assigned to investigate, collect information, and recommend action or closure to the appropriate governing body.

All complaint investigations are confidential. Should the investigation conclude with a decision for disciplinary action against a professional’s license and ability to practice, the name of the license holder will then be made public.

Complaint investigations focus on licensure and fitness of the licensee to practice. Disciplinary action, when warranted, ranges from warning to revocation of license, based on the circumstances. You should not expect a return of fees paid or additional unpaid services as part of the results of this process. If you seek restitution of this nature, consider consulting with the Consumer Protection Division of the Office of the Attorney General, retaining an attorney, or filing a case in Small Claims Court.

Definitions of Unprofessional Conduct

V.S.A.; Title 3: Executive; Chapter 5: Secretary of State; Subchapter 003: Professional Regulation; § 129a defines unprofessional conduct for all mental health professionals as:

(a) In addition to any other provision of law, the following conduct by a licensee constitutes unprofessional conduct. When that conduct is by an applicant or person who later becomes an applicant, it may constitute grounds for denial of a license or other disciplinary action. Any one of the following items, or any combination of items, whether or not the conduct at issue was committed within or outside the state, shall constitute unprofessional conduct:
(1) Fraudulent or deceptive procurement or use of a  license.
(2) Advertising that is intended or has a tendency to deceive.
(3) Failing to comply with provisions of federal or state statutes or rules   governing the practice of the profession.
(4) Failing to comply with an order of the Board or violating any term or condition of a license restricted by the board.
(5) Practicing the profession when medically or psychologically unfit to do so.
(6) Delegating professional responsibilities to a person whom the licensed professional knows, or has reason to know, is not qualified by training, experience, education, or licensing credentials to perform them, or knowingly providing professional supervision or serving as a preceptor to a person who has not been licensed or registered as required by the laws of that person’s profession.
(7) Willfully making or filing false reports or records in the practice of the profession; willfully impeding or obstructing the proper making or filing of reports or records or willfully failing to file the proper reports or records.
(8) Failing to make available promptly to a person using professional health care services, that person’s representative, succeeding health care professionals or institutions, upon written request and direction of the person using professional health care services, copies of that person’s records in the possession or under the control of the licensed practitioner.
(9) Failing to retain client records for a period of seven years, unless laws specific to the profession allow for a shorter retention period. When other laws or agency rules require retention for a longer period of time, the longer retention period shall apply.
(10) Conviction of a crime related to the practice of the profession or conviction of a felony, whether or not related to the practice of the profession.
(11) Failing to report to the office a conviction of any felony or any offense related to the practice of the profession in a Vermont district court, a Vermont superior court, a federal court, or a court outside Vermont within 30 days.
(12) Exercising undue influence on or taking improper advantage of a person using professional services, or promoting the sale of services or goods in a manner which exploits a person for the financial gain of the practitioner or a third party.
(13) Performing treatments or providing services which the licensee is not qualified to perform or which are beyond the scope of the licensee’s education, training, capabilities, experience, or scope of practice.
(14) Failing to report to the office within 30 days a change of name or address.
(15) Failing to exercise independent professional judgment in the performance of licensed activities when that judgment is necessary to avoid action repugnant to the obligations of the profession.

(b) Failure to practice competently by reason of any cause on a single occasion or on multiple occasions may constitute unprofessional conduct, whether actual injury to a client, patient, or customer has occurred. Failure to practice competently includes:
(1) Performance of unsafe or unacceptable patient or client care; or
(2) Failure to conform to the essential standards of acceptable and prevailing practice.

(c) The burden of proof in a disciplinary action shall be on the state to show by a preponderance of the evidence that the person has engaged in unprofessional conduct.

(d) After hearing, and upon a finding of unprofessional conduct, a board or an administrative law officer may take disciplinary action against a licensee or applicant, including imposing an administrative penalty not to exceed $1,000.00 for each unprofessional conduct violation. Any money received under this subsection shall be deposited in the professional regulatory fee fund established in section 124 of this title for the purpose of providing education and training for board members and advisor appointees. The director shall detail in the annual report receipts and expenses from money received under this subsection.

(e) In the case where a standard of unprofessional conduct as set forth in this section conflicts with a standard set forth in a specific board’s statute or rule, the standard that is most protective of the public shall govern. (Added 1997, No. 40, § 5; amended 2001, No. 151 (Adj. Sess.), § 2, eff. June 27, 2002; 2003, No. 60, § 2; 2005, No. 27, § 5; 2005, No. 148 (Adj. Sess.), § 4; 2009, No. 35, § 2; 2011, No. 66, § 3, eff. June 1, 2011; 2011, No. 116 (Adj. Sess.), § 5.)

Psychologists

Unprofessional conduct for psychologists is defined by V.S.A.; Title 26: Professions and Occupations; Chapter 55: Psychologists; § 3016 as the following.

Unprofessional conduct means the conduct listed in this section and in 3 V.S.A. § 129a:

(1) Failing to make available, upon written request of a person using psychological services to succeeding health care professionals or institutions, copies of that person’s records in the possession or under the control of the licensee.
(2) Failing to use a complete title in professional activity.
(3) Conduct which evidences moral unfitness to practice psychology.
(4) Engaging in any sexual conduct with a client, or with the immediate family member of a client, with whom the licensee has had a professional relationship within the previous two years.
(5) Harassing, intimidating, or abusing a client or patient.
(6) Entering into an additional relationship with a client, supervisee, research participant, or student that might impair the psychologist’s objectivity or otherwise interfere with the psychologist’s professional obligations.
(7) Practicing outside or beyond a psychologist’s area of training or competence without appropriate supervision.
(8) In the course of practice, failure to use and exercise that degree of care, skill, and proficiency which is commonly exercised by the ordinary skillful, careful, and prudent psychologist engaged in similar practice under the same or similar conditions, whether or not actual injury to a client or patient has occurred.
(9) Conduct which violates the “Ethical Principles of Psychologists and Code of Conduct” of the American Psychological Association, effective December 1, 1992, or its successor principles and code.
(10) Conduct which violates the “ASPPB Code of Conduct-1990” of the Association of State and Provincial Psychology Boards, or its successor code.

Dr. Petty’s Professional Qualifications

(Last updated 01/18/20)

CURRICULUM VITAE
Green Mountain Forensics
John Petty, Psy.D.
PO Box 600
Putney, Vermont 05346
Phone: 802-258-1222

Current Experience
12/15- Clinical Psychologist. Green Mountain Forensics. Putney, VT. Specializing in
evaluation of adult, adolescent, and intellectually disabled male offenders: Psychosexual evaluations, Protective Services Risk of Harm for Sexual Abuse evaluations, and Nonsexual Violent Offender Risk evaluations. Such evaluations involve record review, clinical interviewing, psychodiagnostic and/or intellectual and/or neuropsychological screening testing, various state of the art actuarial and dynamic risk assessment instruments, as well as Structured Professional Judgment checklists such as the SVR-20 and VCR-2V3. When appropriate, the Hare Psychopathy Checklist-Revised (PCL-R) and Violence Risk Appraisal Guide-Revised (VRAG-R) are used. I also provide staff trainings, presentations, and expert witness testimony.

08/16- Psychological Consultant. Vermont Department of Children and Families, Disability Determination Services (DDS). Waterbury, VT. The DDS uses licensed psychologists for assessment of psychological severity and mental residual functional capacity of individuals applying for Social Security Disability or Social Security Incapacity.
Duties include:
• Reviewing disability cases (primarily in electronic format)
• Assessing medical severity and residual functional capacity, based on case evidence
• Contacting medical sources for further information and/or clarification of their reports
• Providing consultation to adjudicators on case assessment and development issues
• Reviewing and approving adjudicator-completed case assessments
• Providing training on programmatic medical issues to DDS staff, medical consultants, and the medical community upon request

Previous Experience
12/95-08/16 Consultant/Evaluator. Resolutions Programs. Montpelier, VT. Psychosexual evaluations or protective services risk of harm of sexual abuse evaluations of adult, adolescent, and intellectually disabled male sex offenders; psychodiagnostic testing, and risk assessments. Expert witness testimony.
Supervised by Saul Schoenberg, M.A. (VT Licensed Psychologist-Master).

12/87-12/15 Private Practice/Contract Consultant. Founder. Vermont Center for a Safer Society. Emphasis on outpatient psychosexual evaluations (adult & adolescent), and/or cognitive behavioral relapse prevention group treatment of adult sexual offenders referred by the Vermont Department of Corrections. Expert witness testimony. Group supervision by Robert McGrath, M.A. (VT Licensed
Psychologist-Master) and peers. Supervised by Kraig Libstag, Ed.D. (VT Licensed Psychologist-Doctorate) from 03/97-2001. From 2001 forward, the focus was on consulting/contracting to other organizations.

07/87-05/15 Contract Consultant/Program Evaluator. Vermont Treatment Program for Sexual Abusers (VTPSA). I conducted psychosexual evaluations and risk assessments of incarcerated adult male sexual offenders for the Vermont Treatment Program for Sexual Abusers (VTPSA). I used state of the art actuarial and dynamic risk assessment instruments. I provided expert witness testimony as necessary. My reports were co-signed by VTPSA Clinical Director, Robert McGrath, M.A. (VT Licensed Psychologist-Master) from 11/95 until 04/15/14. Then, my reports were co-signed by Associate
Clinical Director, Melanie Williams, M.A. (VT Licensed Psychologist-Master). Previously, I was supervised by William Pithers, Ph.D. (VT Licensed Psychologist-Doctorate) until 11/95.

11/97-06/04 Contract Consultant/Evaluator. Risk assessments of nonsexual violent offenders focusing on use of the PCL-R, VRAG, and LSI-R. Supervised by Thomas A. Powell, Ph.D. (VT Licensed Psychologist-Doctorate), Clinical Director of VT Department of Corrections.

02/93-03/99 Program Consultant. Bennington School Inc. I provided juvenile psychosexual evaluations and residential group and individual treatment to male adolescent sexual offenders. I also consulted with individual clinicians. I was supervised by Lee Gallagher, LICSW, and Francis Moriarty Ed.D. (VT Licensed Psychologist-Doctorate).

05/90-05/95 Program Consultant. Outpatient plethysmograph assessments/psychosexual evaluations for New Hampshire adult sex offender treatment programs not having this capability.

04/87-06/89 Consultant. West Central Services Sexual Abuse Treatment Team. I administered and interpreted plethysmograph assessments, conducted clinical interviews and compiled summary psychosexual evaluations. I was the primary therapist for two weekly child molester groups, one weekly behavioral treatment group and one monthly aftercare group. I attended weekly treatment team staff meetings and provided expert witness testimony when necessary. I was supervised by Anna
Salter, Ph.D. (VT & NH Licensed Psychologist-Doctorate) and treatment team peers.

06/85-03/88 Hospital Social Worker. Brattleboro Memorial Hospital. As hospital social worker, I provided inpatient and outpatient crisis and medical social work services. I facilitated a cardiac rehabilitation group as well as an Alzheimer’s caregivers’ support group. Supervised by Katherine Mason, LICSW.

03/84-07/85 Sex Offender Therapist. Mental Health Services of Southeastern Vermont (MHSSV). I was the primary therapist for a weekly outpatient child molester group. This was the second outpatient sex offender treatment group established in the state. I provided assessments, consultations and expert witness testimony. I was supervised by the MHSSV Brattleboro area manager, a VT licensed psychologist.

02/81- 05/85 Emergency Services Specialist. Mental Health Services of Southeastern Vermont. As a Designated Mental Health Professional, I was a member of a rotating on-call team that specialized in emergency psychiatric assessments, commitments and crisis interventions. I provided crisis intervention counseling to agency patients with chronic mental illnesses. I was supervised by Dorothy King, M.A. (VT Licensed Psychologist-Master) and the rotating psychiatrists on-call.

07/77-03/81 Protective and Juvenile Services Social Worker. Social and Rehabilitation Services, Brattleboro, VT. I provided child protection and family assessment services, including, when necessary, legal interventions involving placement of at-risk/abused children and unmanageable or delinquent adolescents in state custody. I provided case management and emergency services to youth in placement. I also provided supervision, training, and support services to licensed foster parents. I was supervised by the casework supervisor and district director.

10/74-10/76 Substance Abuse Counselor. Franklin County (NY) Mental Health Services. I provided individual counseling and crisis intervention services primarily to adolescents referred for substance issues. I also provided values clarification classes in county high school health classes as outreach. I was supervised by the psychiatrist/Medical Director.

04/74-10/74 Upward Bound Counselor. SUNY Plattsburgh. I provided individual and crisis counseling to high school students accepted into the Upward Bound Program. These students came from low-income families in which neither parent held a college degree, or from families of first generation military veterans. I was supervised by the Program Director.

Education
2013 Psy.D. (Clinical Psychology). Union Institute & University, Cincinnati, OH & Brattleboro, VT.
2012 M.A. (Clinical Psychology). Union Institute & University, Cincinnati, OH & Brattleboro, VT.
1973 M.Ed. (Counseling). St. Lawrence University, Canton, NY.
1972 B.S. (Social Sciences). Clarkson College of Technology, Potsdam, NY.

Professional Organizations
08/08- American Psychological Association.
07/89- Association for the Treatment of Sexual Abusers.

Public Service
01/03-08/08 Guardian ad Litem. Windham (VT) Family & District Courts. As a volunteer advisor, I advocated for, oversaw provision of services and safeguarded the ward’s best interests and rights. Most wards were children or adolescents, but some were adults deemed non-competent by the courts.

04/83-02/87 Volunteer Director. Brattleboro (VT) Nurturing Parent Program. I developed the first Windham County based child abuse prevention/parenting program supported through Parents Anonymous. Responsibilities included recruitment/training of adult volunteer professional trainers, alternated between leader of parent education component and children education component, outreach, public relations, and fundraising.

08/73-09/76 Crisis Counselor. Plattsburgh (NY) Community Crisis Center. As a trained volunteer, I provided telephone and face-to-face crisis intervention services involving substance abuse, suicide, pregnancy, and mental health issues. As part of an outreach team, I provided psychoeducational presentations to high school students around values clarification. I later became involved in the recruitment and training of new volunteers.

Licenses, Certifications, and Credentials
10/16 Registered as a National Register Behavioral Health Psychologist
02/16 Certification for the Violence Risk Appraisal Guide-Revised (VRAG-R)
11/15 Vermont Licensed Psychologist-Doctorate. Credential: # 048.0110630.
01/13 Certification for the Sex Offender Treatment Intervention and Progress Scale (SOTIPS).
10/97 Certification for the Hare Psychopathy Checklist-Revised (PCL-R). Certificate: # 97-103.

Publications and Productions
Petty, J. (2013). Extreme psychopathy: Document review of male sexual offenders who score extremely high on the Hare psychopathy checklist. Doctoral Dissertation. Retrieved from http://search.proquest.com/docview/1443873010?accountid=14436

Pithers, W. D., Beal, L. S., Armstrong, J., & Petty, J. (1989). Identification of risk factors through clinical interviews and analysis of records. In D. R. Laws (Ed.), Relapse prevention with sex offenders. (pp. 77-87). New York, NY US: Guilford Press.

Pithers, W. D. (Producer). (1989). Penile plethysmography: Before your assessment begins [Videotape]. Available from Vermont Center for Prevention and Treatment of Sexual Abuse.

Pithers, W. D. (Producer). (1989). Behavioral therapy with sex offenders [Videotape]. Available from Vermont Center for Prevention and Treatment of Sexual Abuse.

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Green Mountain Forensics
Electronic Communication Policy

In order to maintain clarity regarding our use of electronic modes of communication during our involvement, I have prepared the following policy. This is because the use of various types of electronic communications is common in our society, and many individuals believe this is the preferred method of communication with others, whether their relationships are social or professional. Many of these common modes of communication, however, put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of our involvement and to assure that it is consistent with ethics and the law.

If you have any questions about this policy, please feel free to discuss this with me.

Email Communications

I use email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. That means that email exchanges and text messages with my office should be limited to things like setting and changing appointments, billing matters, or other related issues. Please do not email me about clinical matters because email is not a secure way to contact me. If you need to discuss a clinical matter with me, please feel free to call me so we can discuss it on the telephone or wait so we can discuss it during our time together. The telephone or face-to-face context simply is much more secure as a mode of communication.

Text Messaging

Because text messaging is a very unsecure and impersonal mode of communication, I do not text message to nor do I respond to text messages from anyone with whom I am working. So, please do not text message me unless we have made other arrangements.

Social Media

I do not communicate with, or contact, any of my clients through social media platforms like Twitter and Facebook. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. This is because these types of casual social contacts can create significant security risks for you.

I participate on various social networks, but not in my professional capacity. If you have an online presence, there is a possibility that you may encounter me by accident. If that occurs, please discuss it with me during our time together. I believe that any communications with clients online have a high potential to compromise the professional relationship. In addition, please do not try to contact me in this way. I will not respond and will terminate any online contact no matter how accidental.

Websites

I have a website that you are free to access. I use it for professional reasons to provide information to others about me and my practice. You are welcome to access and review the information that I have on my website and, if you have questions about it, we should discuss this during our time together.

Web Searches

I will use web searches to gather information about you; if anything concerning arises, I will discuss it with you. I understand that you might choose to gather information about me in this way also. In this day and age there is an incredible amount of information available about individuals on the Internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can deal with it and its potential impact on our working together.

Recently it has become fashionable for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on our involvement. Please do not rate my work with you while we are in treatment together on any of these websites. This is because it has a significant potential to damage our ability to work together.

I have had this consent fully explained to me by Dr. Petty, fully understand it, and give my consent.

Signed:_________________________________________________________

Date:________________

I have fully explained this consent to the above-named person and he has said that he fully understands it and consents. I have witnessed his signature above so indicating.

_______________________________________________________________

Date:________________