Questionnaire for Attorneys (CRIMINAL)

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1. I am the:
Public/Private Defense Attorney
District Attorney
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2. Inquiring about:
Competency to Proceed
Mental Status at Time of Offense (“insanity”)
Risk Assessment (e.g., sex offender)
Death Penalty
Mitigation
Sentencing
Specific Intent
Diminished Capacity
Other
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Inquiring about Competency to Proceed
Competency to stand trial
Plead guilty
Waive one’s right to counsel
Competency to be sentenced
Competency to be executed
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3. To your knowledge, does the Defendant have a history of Traumatic Brain Injury (TBI)? Leave Blank if Unknown
YESNO
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4. To your knowledge, has the Defendant already undergone a forensic psychological and/or neuropsychological evaluation specific to this case?
YESNO
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If so, When (mm/yyyy) ? mm/yyyy
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5. Is there a timeframe in which the Defendant would need to be evaluated?
Within the next month
Within the next 2-3 months
Within the next 4-6 months
Undetermined
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Please provide your contact information:
Name:
Law Firm:
Phone:
E-mail:
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How would you prefer to be contacted?
Email
Phone Call
Text
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Please upload any relevant medical and/or legal records to our secure HIPPA compliant database, so that we may review the case appropriately prior to responding to this inquiry. Helpful documents can include: • Charging documents/Arrest reports/Rap Sheet • Previous neuropsychological and/or psychological and/or academic evaluation reports • Any brain/head neuroimaging result reports • Reports from specialty providers (e.g., neurology, psychologist, psychiatrist).
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