Dr. Nicole Graham
Phone: 954-766-8826 Fax: 954-509-0007
Referral Information
This form, along with relevant discovery, must be returned in order to schedule an appointment with Dr. Graham. In addition to any verbal communication with Dr. Graham, this written documentation of referral is required on file.
In order to direct you to the correct referral form, please select the type of case:
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Criminal
Civil
Other (e.g., Fitness for Duty; Immigration; School Violence Risk)
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Case Information
Criminal Matters
1. Attorney Information:
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1. Examinee (Defendant) Information:
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1. Examinee Location:
In-Custody - Identify facility; Out-of-Custody: Provide Residential City & Phone Number
1. Next Court Date (if known):
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Month
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Day
Year
Date
1. Type of Evaluation Requested (each evaluation is a separate fee)
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Competency to Proceed
Competency to Testify
Sanity
Downward Departure / Mitigation
Juvenile Waiver
Juvenile Re-Sentencing
Neuropsychological
Substance Abuse
Miranda Waiver
Violence Risk Assessment
Sexual Offending Risk Assessment (Psychosexual)
Sex Offender Civil Commitment
Document Review & Consultation
1. Legal Issue(s) you wish to address / Reason for Evaluation:
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Provide explanation for your concerns relevant to the type of referral requested. Please fully complete this section even if you have spoken to Dr. Graham regarding this matter.
1. Funding Source:
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Private Hire
JAC: Indigent for Costs
Public Defender's Office
Federal Public Defender
Attorney General's Office
State Attorney's Office
Federal Prosecution
CJA
RC-4 (ORCC)
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Case Information
Civil Matters
2. Attorney Information:
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2. Examinee (Client) Information:
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2. Next Court Date (if known):
-
Month
-
Day
Year
Date
2. Provide the Residential City of the Examinee and Information to Contact the Examinee:
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2. Type of Evaluation Requested (each evaluation is a separate fee):
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Guardianship / Decisional Capacity
Personal Injury Assessment
Immigration
Document Review and/or Consultation
2. Legal Issue(s) you wish to address / Reason for Evaluation:
*
Provide explanation for your concerns relevant to the type of referral requested. Please fully complete this section even if you have spoken to Dr. Graham regarding this matter.
2. Please identify the Funding Source and Contact Information:
*
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Case Information
3. Please provide the following information about the Referring Agency / Party:
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3. Examinee (Client) Name:
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First Name
Last Name
3. Provide the Residential City of the Examinee and Information to Contact the Examinee:
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3. Provide any additional, relevant contact information or legally-relevant information:
(E.g., if an attorney is involved or if additional agencies are involved -- provide their contact information)
3. Type of Evaluation (each evaluation is a separate fee)
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Fitness for Duty
Immigration
School-Based Violence / Risk Assessment
Document Review and/or Consultation
3. Describe the reason for this evaluation. What relevant concerns or questions have prompted a psychological evaluation?
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Please fully complete this section even if you have spoken to Dr. Graham regarding this matter.
3. Please identify the Funding Source and Contact Information:
*
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Individual Completing this Form:
Association to Examinee:
(e.g., Defense Attorney; Attorney Assistant; Prosecutor; Employer; Agency Member)
Use this space to provide additional contact or case-related information as needed:
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