Competency Evaluation Intake

The following form is an intake form for a Competency Evaluation.

Description:
Court-ordered competency evaluations are specialized assessments used to determine an individual's mental capacity to participate in legal proceedings.
Are you scheduled for a competency evaluation?

YesNo
Based on your response, you do not need to complete this form. This form is only needed if you are scheduled for a Competency Evaluation. Please close this window
Thank you for confirming. Please proceed to the next page to complete your intake form.

Competency Evaluation Intake

Please fill out all fields completely.
Today's Date: *

MonthDayYear
Date
Who is filling out this form?

The client receiving the evaluation (myself)Another party acting on behalf of the client receiving the evaluation
Full Legal Name of party filling out this form for the client: *

First NameMiddle NameLast Name
Relationship to client receiving evaluation: *
Phone Number of party filling out this form for client: *
Please enter a valid phone number.
Demographic Information of Client Receiving Evaluation:

Please fill out the information below to the best of your ability.
Full Legal Name:*

First NameMiddle NameLast Name
Date of Birth: *

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email
Ex: email@email.com
Current Address of Client: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status:*

SingleMarriedDivorcedSeparatedWidowed
Legal Name of Spouse (whether married, separated, divorced, or widowed):

First NameMiddle NameLast Name
Spouse Date of Birth:

MonthDayYear
Date Married:

MonthDayYear
Date
Date Separated:

MonthDayYear
Date
Date Divorced

MonthDayYear
Date
Date of Death:

MonthDayYear
Date
Does the client have children?*

YesNoUnsure

Additional Comments, if applicable:
By signing below, I attest that the information given above is accurate to the best of my knowledge. *

Clear
Should be Empty:

Demographic Information of Client Receiving Evaluation: