For example, “John Q. Public, Assistant State Attorney referred this case on June· xx, 2030. ” The judge in a case may be the only cited source of referral when initial communications involving the case excluded the assigned attorneys at the time of referral. Also include here a recitation of the referral question and discussion of notices regarding the nature and purpose of evaluation, absence of confidentiality, and any applicable privilege, as well as the examinee’s understanding of this notice.
Current Evaluator: Name, degree, title (optional if using letterhead with the same information Date(s) of Evaluation: . Date of Report: Month, Day, Year General Finding(s): recommended disposition (e. g. Competent to Proceed, Incompetent to Proceed, Insanity Opinion) Ill. SOURCES OF INFORMATION: Provide in this section a listing of all sources of information considered or reviewed (e. g. , interview (note how much time was devoted to an interview); psychological testing; review of arrest reports or other third party documents such as depositions, medical records, criminal justice records, or school records; interview with others such as family members, arresting officers, jail staff, treating health care professionals).
IV. RELEVANT HISTORY: The historical section is a compilation of narrative information describing past events indicative of an individual’s psychosocial functioning across time. The evaluator must apply clinical judgment when considering the relevance and accuracy of all sources of information, including the defendant’s accounts and third party accounts and records.
The evaluator should report the use of third party information, as appropriate, relevant to the referral questions. CONFIDENTIAL AND PRIVILEDGED INFORMATION For Professional Use Only FORENSIC MENTAL HEALTH ASSESSMENT Re: Defendant’s Name Date of Report: Page 2 of4 V. CURRENT CLINICAL PRESENTATION/BEHAVIORAL OBSERVATIONS: Offered in this section is a narrative description of an individual’s presentation during the evaluation.
Periodically, clinicians may rely on observational data or other data as appropriate when individuals refuse to participate in the process of evaluation. This section typically includes, but is not limited to descriptions of grooming and hygiene, cooperation, motivation, response style, eye contact, appetite/sleep, recent and remote capacities of memory, speech, thought processes, mood, affect, suicidal and homicidal ideation and planning, hallucinations, delusions, and insight and judgment. Bulleted content follows for quick reference. • physical description including hygiene and grooming
• response style (reliable/honest, malingering, defensive, relevance/irrelevance, cooperative/uncooperative, impaired/unimpaired) • eye contact • appetite/sleep • recent and remote memory • speech • thought processes • mood • affect • suicidal and homicidal ideation and planning • hallucinations • delusions • insight and judgment The evaluator may select a structured clinical interview as appropriate (when using structured interviews, the evaluator should remain cognizant of applicable ethical standards of his or her profession and the legal standards regarding the use of instruments). Regardless
of the clinical evaluation approach, evaluators should provide underlying facts when communicating conclusions/opinions. For example, if offering the opinion that the defendant is “paranoid,” the evaluator should provide the underlying facts, the statements and behaviors that support this opinion. If the evaluator is of the opinion, that the defendant is “delusional,” the evaluator should provide the underlying facts.
For example, “the defendant stated and seemed to believe that he was the King of the Universe. ” If the evaluator concluded the defendant was depressed, the evaluator should provide the underlying facts or other supportive facts. For example “the defendant reported a sad mood, which was consistent with his presentation which included a sullen facial expression, some crying, self blame, a lack of eye contact, and a paucity of speech.
Records in the jail indicate that he sleeps approximately sixteen hours each day. Relevant Assessments. The evaluator shall report the results of relevant testing and assessments completed by the examiner or referenced in third party documents. The evaluator should typically describe the purpose of each test or assessment instrument prior to presenting results and interpretations to the court. Relevant assessments may include but are not limited to estimations of intelligence, psychiatric functioning, neurological functioning, psychopathy, response style, etc.
The CONFIDENTIAL AND PRIVILEDGED INFORMATION For Professional Use Only FORENSIC MENTAL HEALTH ASSESSMENT Re: Defendant’s Name Date of Report: Page 3 of4 evaluator should remain cognizant of the applicable ethical standards of his or her profession and the legal standards regarding the use of tests. DSM-IV Diagnoses Relevant to the Referral Questions.
[Include the following statement before reporting diagnoses]. Inclusion of a DSM-IV diagnosis in this report does not imply that the condition meets legal or other non-medical criteria for what constitutes mental disease or infirmary, mental disorders, insanity, competency and involuntary hospitalization or release.
There may be other DSM-IV diagnoses that are not offered below, which are not considered relevant to the psycholegal issues that are the focus of this evaluation. Axis 1: report diagnoses relevant to the issue of competency to proceed or mental state at the time of the offense Axis II: report diagnoses relevant to the issue of competency to proceed or mental state at the time of the offense Axis Ill: report diagnoses relevant to the issue of competency to proceed or mental state at the time of the offense VI.
COMPETENCE TO PROCEED [if ordered or requested]: The evaluator shall support all opinions by reporting facts/observations/data on which the opinions are based (e. g. , specific statements or behaviors of the examinee). Specific statements the defendant offered regarding his behavior around the time of the alleged offense should not be provided when only addressing competency to proceed. Headings in the report to organize competency related information follow this paragraph. Appreciation of charges. Appreciation of possible penalties.
Appreciation of the adversarial nature of the legal process. Ability to disclose pertinent facts to defense attorney. Capacity for appropriate courtroom behavior. Capacity to testify relevantly. Other factors. Evaluators selecting instruments to guide decision-making, e. g. , the Fitness Interview Test- Revised, should remain cognizant of applicable ethical and legal standards regarding the use of tests.
VII. MENTAL STATE AT THE TIME OF THE ALLEGED OFFENSE [if ordered or requested]: The examiner should offer a comprehensive description of the defendant’s behavior, cognitions, and emotional functioning at and around the time or the alleged offense, based upon consideration of the CONFIDENTIAL AND PRIVILEDGED INFORMATION For Professional Use Only FORENSIC MENTAL HEALTH ASSESSMENT Re: Defendant’s Name Date of Report: Page 4 of4 defendant’s self-repot and relevant third party sources of information (e. g. , police reports, witness statements).
The examiner should describe the relationship between the defendant’s behavioral, cognitive, and emotional functioning and his or her ability to understand the nature and consequence of his/her actions, and distinguish between right and wrong at and around the time of the alleged offense. VIII. OTHER REFERRAL ISSUES [if ordered or requested]: IX. CONCLUSIONS AND RECOMMENDATIONS: Opinion regarding competency [if ordered or requested].
This section shall include a report of the evaluator’s recommendation regarding whether the defendant should be adjudicated competent or incompetent to participate in legal proceedings. A brief but accurate rationale supporting the opinion · should be included.
The evaluator should provide a more extensive explanation or rationale for an opinion of competency in the context of recent symptoms/behaviors that appear to inconsistent with the opinion. For example, the evaluator should explain why she believes the defendant is competent, notwithstanding his or her continuing paranoid thoughts. Opinion regarding mental state at the time of the alleged offense [if ordered or requested]. Opinion regarding the need for involuntary hospitalization for [if ordered and requested]. The evaluator should report whether·the person meets the criteria for involuntary hospitalization.
The evaluator should provide underlying facts to support his or her opinion. Other. Recommendations. The content of a guideline cannot fully address every recommended outcome. As with any recommendation, the evaluator must apply judgment when determining and communicating the needs of an individual. All evaluators are encouraged to provide sufficient data to allow legal authorities and community providers opportunities to make informed decisions and to establish continuity of care. Writer’s signature Writer’s name; writer’s degree Title License number.