Forensic Evaluation Services-Criminal

Acknowledgment

Date

Today's Date

Last Name of Individual to be Evaluated

First Name of Individual to be Evaluated

Defendant’s Date of Birth

Birthdate

Defendant's Preferred Gender

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

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

Please select the following evaluation(s) that have been ordered (select all that apply that are noted on the court order): OTHER TYPES OF EVALUATIONS

Referring Court or Agency

Who is ordering this evaluation take place? (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.

Defendant Address (Please include their personal address in the case they are released on bond while detained.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is the defendant residing in a facility at this time?

Name of Facility/Institution

Defendant Personal Number

Entering a valid phone number is REQUIRED, even if they are detained, in the case they are released on bond.Format: (000) 000-0000.

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

First NameLast Name

Defense Attorney Email Address

example@example.com

Defense Attorney 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 defendant, if applicable.

Prosecuting Attorney Name

First NameLast Name

Prosecuting Attorney Email Address

example@example.com

Prosecuting Attorney Phone Number

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

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

Docket/Case No.(s) (Include all those applicable)

Present Charges

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, probation, 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: