Your Heading
Clinical and Forensic Psychology
California License No. your license
NPI our NPI number
DATE
Honorable
Judge of the Superior Court
County of
Courthouse
City
RE:
Case No.
Exam Pursuant to PC Section 288 (CA sex offender)
Dear Judge
Pursuant to request, a psycho-legal examination was conducted upon ***** regarding the following questions:
I. QUESTIONS BEFORE THIS EXAMINATION:
1. Is this defendant a danger to the community as the result of a sexual perversion? Is this defendant a pedophile? Is this defendant a sexual predator?
2. Does this defendant need psychological treatment and, if so, what is needed? Is the defendant amenable to rehabilitation? What is the defendant’s potential for positive response to treatment? Is there a recognized treatment program in the local area designed to deal with child molestation?
3. Should the defendant be allowed contact with the victim? Is there a threat of physical harm to the victim if a grant of probation is made?
4. Is a grant of probation to the defendant in the best interest of the victim?
Street Address: our address Mail Address: your email address
E-Mail: our e-mail address Telephone: your phone Fax: your fax
II. PERSONAL IDENTIFYING INFORMATION:
NAME: GENDER:
BIRTHDATE: AGE:
MARITAL STATUS:
CHILDREN:
ETHNICITY: LANGUAGE:
III. CASE IDENTIFYING INFORMATION:
COURT CASE NO(S):
ATTORNEY: COUNTY:
VICTIM INFORMATION:
NEXT COURT DATE:
IV. EXAMINATION PROCESS INFORMATION:
EXAM DATE(S): 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.
4.
VI. BASIS FOR OPINIONS BEFORE THIS EXAMINATION:
Opinions are based upon the review of the records, interview with the defendant, and psychological testing with the defendant.
VII. REVIEW OF PSYCHOLOGICAL SYSTEMS:
Depression:
Anxiety:
Mania:
Obsessions/Compulsions:
Psychosis:
Fears/Worry:
PTSD:
ADHD/ADD:
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 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:
E. Vocational/Financial Support History:
F. Military History:
G. Medical History:
H. Mental Health History:
I. Assault/Abuse/Social Mistreatment History:
J. Sexual History:
K. Spirituality:
L. Habits/Interests:
M. Legal History:
X. 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/Assaultiveness:
XI. PSYCHOLOGICAL TESTING RESULTS:
A. MCMI-III:
B. Static 99R: This is an evaluative process developed in Canada with the attempt to predict potential recidivism for sexual assault. It is used in conjunction with the SVR-20. The revised Static 99R does address some dynamic factors as well as static factors related to sexual assault. It is an instrument used by the California Department of Corrections in the SVP Unit to assess inmates convicted of sexual offenses. This instrument is scored using victim and legal variables and results in a score of ‘low,’ ‘medium-low,’ ‘medium-high,’ or ‘high’ relative to the risk of future sexual violence.
C. SVR-20: This is an evaluative process developed in Canada with the attempt to predict potential recidivism for sexual assault. It is termed sexual violence because the developers took the position that any unwanted sexual contact is a form of violence. The item is scored using a number of personal psychological, legal, victim and social variables. The item results in a score of ‘low,’ ‘moderate,’ or ‘high’ relative to the risk of future sexual violence.
D. MSI II: The MSI II is a theory based, nationally standardized self-report questionnaire designed to assess the wide range of psychosexual characteristics of the sexual offender. It may be classified as a special category of personality testing. It is a battery of forty scales and indices with the addition of a compact social history; all of which have been developed for use by clinicians who evaluate and treat sexual offenders. The instrument contains 560 True-False test items.
XII. INTERVIEW REGARDING ISSUES IN P.C. SECTION 288.1:
A. Defendant’s Stated Circumstances of Offense:
B. Victim Related Issues:
C. PC Section 1203.066 (2), (3), (4):
D. Pedophiliac Interest:
Problem Shown Potential Problem Area
YES NO Fail to take responsibility for actions
YES NO Sense of entitlement
YES NO Low self-esteem
YES NO Need power/control
YES NO Lack empathy
YES NO Psychopathic tendencies
YES NO Poor intimate relations with adults
YES NO Relate better to children than adults
YES NO Photographs of children
YES NO Photographs of victim(s)
YES NO Volunteer in child organization
YES NO Pornography/child content
YES NO History of own abuse
YES NO Troubled childhood
YES NO Deviant sexual behaviors/attitudes
XIII. POTENTIAL FOR PSYCHOLOGICAL DISTORTION:
XIV. SUMMARY AND CONCLUSIONS:
Thank you for this referral. If further information or clarification is needed, please
contact me.
Respectfully submitted,