Court Reports Initial Evaluation Form

Free Initial Case Evaluation Form

Why fill out this form?

Our psychiatric mental health assessments support clients and courts in criminal, civil, motor vehicle cases and other matters. Your confidential preliminary information helps us evaluate how we can best assist you with the necessary assessments and reports.

Instructions:

Please complete all fields to the best of your knowledge.
Select the appropriate options where available.
This form should take approximately 10 minutes to complete.

Your First Name*

Your Middle Name(s)

Your Last Name*

Are you a Maryland resident?*

Yes

No

Your Date of Birth*

Your Email*

Phone*

Your Address*

City*

State*

ZIP Code*

What type(s) of case(s) are you currently involved in? (select all that apply)*

Criminal

Family

Personal Injury

Motor Vehicle (e.g., DUI, Driving while suspended, etc.)

Other Civil Matters

License/Permit Petition

Other

Other type(s) of case(s)

What are the charges or issues involved in your case?*

Are you currently working with an attorney?*

Yes (please provide attorney's details below)

No

Prefer not to say

Attorney Details

Are you currently working with a mental health provider?*

Yes (please provide provider's details below)

No

Mental health provider details

Why are you seeking a mental health evaluation and court report? (Select all that apply)*

To clarify my mental health status

To support my legal defense or claim

To better understand psychological factors related to my case

To seek a fairer court outcome

The court ordered me to get one

Other (enter the reason below)

Other reason(s) for seeking a mental health evaluation and court report

How did you hear about us?*

Attorney referral (please enter attorney's details below)**

Bail bond company referral (please enter bail company's details below)**

Online search

Social media

Friend/family

Flyer/brochure/business card

Other

**Name and Phone # of Attorney or Bail Bond Company

Will you be comfortable using the following technologies during the evaluation? (If "Yes," select all that apply)*

Secure video conferencing (e.g., Zoom, Google Meet, Webex, etc.)

Electronic document signing (e.g., DocuSign)

Email communication

Fax communication

No, or None of the above

Are you aware that these psychiatric mental health evaluation and report services for court cases may not be covered by insurance and are subject to direct payment?*

Yes

No

Are you willing to cooperate with background checks such as reviewing your court, police, driving, medical, medical, mental health, educational, training, licensing, employment, and other records as may be needed, and submitting copies of diplomas, awards, recognitions, or even documents that may seem adverse, but might help prove your sincerity?*

Yes

No

Will you be able to identify 3-7 individuals who can provide objective references about you in a timely manner? These references should spread across people like family members, acquaintances, friends, colleagues, and then supervisors, mentors, and community leaders (local church leaders, imams, rabbis, school officials, community activists, local business owners, elected officials, etc.).*

Yes

Maybe

No

How willing are you to be open, honest, and cooperative during the actual evaluation?*

Very willing

Somewhat willing

Unsure

Prefer not to say

What would be the most important outcome(s) for you from this evaluation? (Select all that apply)*

A clearer understanding of my mental health status

A stronger defense for my case

Fair treatment in court

Rehabilitative support and guidance

Other (Please specify, below)

Will you be able to write some basic [not perfect] personal essays about yourself and your circumstance? *

Yes

No

Are you aware the evaluation report will be objective and may not reflect everything you want or avoid things you don't wish, which may affect your or your attorney's decision to actually submit it to the court?*

Yes

No

Are you open to working with skilled professionals from diverse backgrounds, including racial minorities, women, and immigrants with accents, as part of your mental health evaluation and report-writing process?*

Yes

No

If you have any additional information or questions, kindly enter them below: (Optional)