Intake Form-Legal Case | Psychological Assess

Legal or Court-Ordered Evaluation Intake Form

Date

Month

Day

Year

Section 1: Personal Information

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Age:

Ethnicity:

Gender:

Emergency Contact: Name, Phone Number , Relationship

Section 2: Legal Referral Details

Referral Source: Court, Probation ,CPS, Attorney, Other: Describe!

Case Type: Criminal, Domestic Violence, Custody, Other: Describe!

Court Case Number: (if applicable)

Judge/Department: (if applicable)

Attorney Name/Number (if applicable)

Evaluation Purpose: Competency, Risk Assessment , Parenting Capacity, Substance Use, Mental Health, Other: Describe!

Reason for Evaluation: Describe your case in Details!

Section 3: Legal History

Have you ever been arrested? Yes , No. If yes, list charges and dates

Are you currently on probation or parole? Yes , No. If Yes, include date from - date to

Have you ever had a restraining order issued against you? Yes , No. If Yes, describe in details include date!

Are you currently involved in a custody dispute? Yes, No. If yes describe.

Have you previously completed a court-ordered evaluation? Yes, No. If yes, when and where:

Section 4: Mental Health History

Have you ever been diagnosed with a mental health condition? Yes, No. If yes, specify:

Have you ever been hospitalized for psychiatric reasons? Yes, No. If yes, describe.

Do you currently see a therapist or psychiatrist? Yes , No. If yes, Provider name.

Are you currently taking psychiatric medications? Yes, No. If yes, list medications:

Section 5: Substance Use

Do you currently use alcohol or drugs?

Yes

No

Have you ever been treated for substance abuse? Yes, No. If yes, where and when!

Substances used in the past 12 months (Write down all used) include frequency of use! Alcohol, Cannabis, Cocaine, Methamphetamine, Opioids, Benzodiazepines, Hallucinogens , Other: Describe!

Have you ever been arrested for DUI or possession? Yes, No. If yes, describe include related dates.

Section 6: Domestic Violence (if applicable)

Name of the alleged victim and Relationship to alleged victim: Spouse, Partner, Ex , Other: Describe!

Nature of incidents: Verbal aggression, Physical violence, Threats, Property damage. Describe in details.

Were children present during incidents? Yes, No. If yes, include relationship and age.

Is there a current restraining order? Yes, No. If yes, provide details.

Have you completed any DV-related programs? Yes, No. If yes, specify:

Section 7: Custody & Parenting (if applicable)

Number of children involved: include Ages.

Current custody arrangement: Sole custody, Joint custody, Supervised visitation, No contact

Concerns raised by other parent or court: Substance use, Mental health, Anger issues, Neglect , Abuse!

Have you completed parenting classes?

Yes

No

Do you live with your children?

Yes

No

Section 8: Current Functioning

Are you currently employed? Yes, No, Occupation

Do you have stable housing? Yes, No. Describe!

Do you have a support system (family, friends)? Yes, No. Describe!

Do you experience any of the following : Depression, Anxiety , Anger issues, Sleep problems, Hallucinations, Memory issues, Suicidal thoughts, None

Section 9: Collateral Sources

Documents available for review : Police reports, CPS records, Medical records, Prior evaluations , Court transcripts, Other: Describe!

Would you consent to release of records from other providers?

Yes

No

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Psychological Assessment and Evaluations

At VCAT Treatment Center Costa Mesa Orange County

Legal or Court-Ordered Evaluation Intake Form