Forensic Evaluation Services-Civil

Acknowledgment:

Date

Today's Date

Last Name of the Individual to be Evaluated

First Name of the Individual to be Evaluated

Evaluated Individual's Date of Birth

Birthdate

Evaluated Individual's Preferred Gender

If this referral is associated with other family members or individuals to be evaluated, please indicate those individuals' names here. (If none, type "N/A.")

Please select the following evaluation(s) that have been ordered (select all that apply that are noted on the court order)

Referring Court or Agency

Who is ordering this evaluation? (e.g., Judge, Magistrate, or other individual name)

Who should we contact if we have questions about this referral?

First NameLast Name

Referral Source Contact Email Address

example@example.com

Referral Source Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Personal Address of Individual to be Evaluated (Please include their personal address even if they are in a facility.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is the individual to be evaluated residing in a facility at this time?

Name of Facility/Institution

Phone Number of Individual to be Evaluated

Entering a valid phone number is REQUIRED, even if they are in a facility.Format: (000) 000-0000.

Attorney Name (If none, type "N/A" in both boxes.)

First NameLast Name

Attorney Email Address

example@example.com

Attorney Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Guardian Ad Litem (GAL) (If none, type "N/A" in both boxes.)*

First NameLast Name

GAL Email Address

example@example.com

GAL Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Name and phone number or email address of family member, legal guardian, or other person to contact individual to be evaluated, if applicable.

Please note the ACTUAL hearing date pertaining to the relevant case. (ONLY answer if a hearing date has been scheduled. If none scheduled, note as TBD.)

Docket/Case No.(s)

Is there anything else you would like us to know about this referral? (e.g., You can add names and contact information for collateral sources or other colleagues, anything not mentioned above that you would like us to know, etc.)

Who will we send the report(s) to? (e.g., judge/magistrate, you as referral contact, etc.)

Is this a correction to a referral already filed?

Please upload the required documents. For security reasons, please DO NOT EMAIL documents to individual CDTC staff members. If need be, we can also send you a shared folder link for transfer or accept/pick up recording materials.

Certification: