Use this typing form as may be useful to you. Copy. Paste. Change as you may need. Just remember where you found this outline.
Your name
Clinical and Forensic Psychology
Your clinical license number
Your NPI number
DATE
TO
RE:
Case No.
Dear
Pursuant to request, a psycho-legal examination was conducted upon ***** regarding the following questions:
I. QUESTIONS BEFORE THIS EXAMINATION:
1.
2.
3.
II. PERSONAL IDENTIFYING INFORMATION:
NAME: GENDER:
BIRTH DATE: AGE:
MARITAL STATUS:
CHILDREN:
ETHNICITY: LANGUAGE:
III. CASE IDENTIFYING INFORMATION:
COURT CASE NO(S):
ATTORNEY: COUNTY:
NEXT COURT DATE:
Street Address: your street Address: your snail mail appress
E-Mail: your email address Telephone: Fax:
IV. EXAMINATION PROCESS INFORMATION:
EXAM DATE: EXAM PLACE:
EXAM INSTRUMENTS:
RIGHTS GIVEN BEFORE INTERVIEW BEGINS: Yes x No
PICTURE IDENTIFICATION CONFIRMATION: Yes No
PSYCHOLOGICAL OPINION
V. OPINIONS REGARDING QUESTIONS BEFORE THIS EXAMINATION:
1.
2.
3.
VI. BASIS FOR OPINIONS BEFORE THIS EXAMINATION:
VII. REVIEW OF CURRENT PSYCHOLOGICAL SYSTEMS/COMPLAINTS:
Depression:
Anxiety:
Mania:
Obsessions/Compulsions:
Psychosis:
Fears/Worry:
PTSD:
ADHD/ADD:
Oppositional/Defiant:
Conduct/Behavior Problems:
Constitution:
Nutritional Status:
PAIN (Organic or Psychological):
Current Psychiatric Medications:
Etiology of Current Psychiatric/Psychological Problem(s):
VIII. DIAGNOSTIC IMPRESSION:
DSM-5: ICD-10:
DATA BASIC TO PSYCHOLOGICAL OPINION
IX. PAST REPORTS AND OTHER DATA REVIEWED:
X. SUICIDE/HOMICIDE RISK ASSESSMENT:
1. Patient/Defendant Statements:
2. Suicide Risk Factors:
3. Homicide Risk Factors:
4. Protective Factors:
5. Examiner Opinion:
XI. TREATMENT NEEDS:
XII. PERTINENT BACKGROUND INFORMATION:
A. Childhood/Developmental History:
B. Adulthood/Relationship History:
C. Educational History:
D. Substance Use History:
Alcohol:
Tobacco:
Caffeine:
Illegal Drugs:
OTC Medication:
E. Vocational/Financial Support History:
F. Military History:
G. Medical History:
Injury:
Current Medications:
Appetite/Weight:
Exercise:
Sleep:
Vitamins/Supplements:
H. Mental Health History:
I. Assault/Abuse/Social Mistreatment History:
J. Sexual History:
Pre-adolescent:
Adolescent:
Adult:
Pornography:
K. Spirituality:
L. Habits/Interests:
M. Legal History:
Juvenile:
Adult:
Felony:
Prison:
XIII. PRESENT PSYCHOLOGICAL STATUS:
A. Behavioral Description:
B. Thought Processes:
C. Cognitive/intellectual Functioning:
D. Affective Processes:
E. Perceptual Processes:
F. Impulse Control:
G. Judgment/Insight:
H. Substance Use/Abuse:
I. Violence/Assaultive:
XIV. PSYCHOLOGICAL TESTING RESULTS:
A.
B.
XV. POTENTIAL FOR PSYCHOLOGICAL DISTORTION:
XVI. SUMMARY AND CONCLUSIONS:
Thank you for this referral. If further information or clarification is needed, please
contact me.
Respectfully submitted,
__________________________________
You, Ph.D. or PsyD
Clinical and Forensic Psychology
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