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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 10-15 minutes to complete.

1. Your First Name*

2. Your Middle Name(s)

3. Your Last Name*

4. Are you a Maryland resident?*

Yes

No

5. When were you born?*

6. Your Email*

7. Your Phone #*

8. Your Street Address*

9. City*

10. State*

11. ZIP Code*

12. 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)

13. Are you currently working with an attorney?*

Yes (please provide attorney's details below)

No

Prefer not to say

Attorney Details

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

15. Are you currently working with a mental health provider?*

Yes (please provide provider's details below)

No

Prefer not to say

Mental health provider details (in any)

16. 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

17. 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

Direct mail or email

Other

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

18. 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

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

Yes

No

20. Are you willing to cooperate with background checks, including reviewing your records (court, police, driving, medical, lab, mental health, education, training, licensing, military, employment, and others as needed) and providing copies of your diplomas, certificates, awards, recommendations, recognitions, or, even, potentially adverse documents? These details can help provide a fuller picture of your life and demonstrate your seriousness and sincerity in addressing your situation. Even sensitive results, like positive drug tests, can offer important context, helping the evaluators accurately assess your circumstances and advocate for fair interventions, such as treatment or restitution instead of incarceration. Are you willing to cooperate at this level?*

Yes

I'm not too sure

No

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

Yes

Maybe

No

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

Very willing

Somewhat willing

Unsure

Prefer not to say

23. 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 or argument for my case

Fair treatment in court

Rehabilitative support and guidance

Other (Please specify, below)

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

Yes

No

25. 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 or hearing?*

Yes

No

26. 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

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

You didn’t come this far to stop.

Believe you can, and you're halfway there.

Theodore Roosevelt

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Murder and manslaughter
Probation or parole petitions or violations
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Robbery
Sex crimes
Theft and larceny
Vandalism
Other felonies or misdemeanor infractions

Adoption
Child custody
Domestic violence
Divorce
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Other family-related cases

Driving under the influence of alcohol or drugs ("DUI", including Boating DUI)
Driving while suspended or revoked
Reckless driving
Hit-and-run
Vehicular homicide
Other motor vehicle-related cases

Assault and battery
Automobile accidents
Boating accidents
Construction accidents
Defective products
Dog bites and animal attacks
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Nursing home negligence or abuse
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Slip and fall accidents
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Wrongful death
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