5070.12 Forensic & Other Mental Health Evaluations

us-doj-guidance-DOJ-13145765070.12 Forensic & Other Mental Health EvaluationsGuidance

Program
Statement
U.S. Department of Justice
Federal Bureau of Prisons
OPI: CPD/PSB
NUMBER: P5070.12
DATE: 4/16/2008
SUBJECT: Forensic and Other
Mental Health
Evaluations
1. PURPOSE AND SCOPE. To describe the procedures the Bureau of
Prisons (Bureau) shall follow to prepare a psychological or
psychiatric evaluation on an inmate committed to its custody for
pretrial and post-trial detention pursuant to Title 18 U.S.C. §§
4241 through 4247 and the pre-sentence stage of trial under Title
18 U.S.C. § 3552(b). These procedures also apply to a defendant
committed by the court for an evaluation during their pre-release
parole eligibility “old law” stage of confinement under Title 18
U.S.C. § 4205 (c), and to a defendant committed by the court for
an evaluation pursuant to Title 18 U.S.C. § 5037(e).
2. PROGRAM OBJECTIVES. The expected results of this program
are:
a. Information concerning an inmate's mental health status and
recommendations will be provided to the court upon request.
b. Forensic Evaluators will provide timely and accurate
responses to referral questions and concerns addressed by the
court.
c. All psychological or psychiatric evaluations will be
forwarded to the courts in a timely manner.
3. SUMMARY OF CHANGES. This Program Statement expands or
modifies earlier policy in the following ways:
a. In addition to earlier types of court-ordered evaluations
referenced, this Program Statement describes procedures used to
complete pretrial and post-trial evaluations governed by Title 18
U.S.C. §§ 4241 through 4247.
b. Requirements clarifying the Chief Psychologist’s
supervision of reports are added.
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c. A section clarifies evaluation requirements pertaining to
inmates who are mentally ill and receive a disciplinary report.
d. The policy specifies evaluation requirements in cases where
the United States Parole Commission or other entities request an
evaluation to assist in determining parole suitability.
4. DIRECTIVES AFFECTED
a. Directive Rescinded
P5070.11 Study and Observation Report (12/31/97)
b. Directives Referenced
P5100.08 Security Designation and Custody Classification
Manual (9/12/06)
P5215.05 Youth Corrections Act YCA), Inmates and Programs
(3/17/99)
P5270.07 Inmate Discipline and Special Housing Units
(12/29/87)
P5310.12 Psychology Services Manual (8/13/93)
P6010.02 Health Services Administration (1/15/05)
P6270.01 Medical Designations and Referral Services for
Federal Prisoners (1/15/05)
5. STANDARDS REFERENCED
a. American Correctional Association 4th Edition Standards for
Adult Correctional Institutions: 4-4372.
b. American Correctional Association 4 Edition Performance	th
Based Standards for Adult Local Detention Facilities: 4-ALDF-4C-
31.
6. INSTITUTION SUPPLEMENTS. None required.
7. DEFINITION OF TERMS. For the purpose of this program
statement, the following definitions apply.
a. Forensic Evaluator - A licensed psychologist or licensed
psychiatrist assigned to complete an evaluation for the Federal
Court System.
b. Non-Study Inmates - All inmates in the Bureau for whom a
Federal judge has not ordered a psychological or psychiatric
evaluation
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c. Study Inmates - Inmates for whom a psychological or
psychiatric evaluation has been ordered by a Federal Court.
8. TRAINING MANUAL “HOW TO CONDUCT A THOROUGH AND PROFESSIONAL
FORENSIC EVALUATION” - FEDERAL BUREAU OF PRISONS. Psychologists
and psychiatrists in the Bureau who engage in any type of
evaluation need to become familiar with the best practice
standards and expectations in the Bureau’s Forensic Training
Manual.
9. EVALUATIONS UNDER TITLE 18 § 3552(B)- PRE-SENTENCE. The
sentencing court may order a local community
psychologist/psychiatrist (LCPP) to complete the evaluation.
Evaluations can be conducted while the defendant is on bail by a
LCPP or in a local facility (Federal or non-Federal) by a LCPP -
Title 18 § 3552(b). If the sentencing judge finds that there is
a compelling reason for the Bureau to do the study or there are
no adequate professional resources available in the community to
perform the study the order may direct the Bureau to complete an
evaluation on a defendant who has been found guilty. The purpose
of this evaluation is to provide additional information that will
aid the court in imposing a final sentence. Ordinarily, the
court will specify what information it requires to assist in the
final determination of sentence.
The evaluator will inquire into those matters specified by the
court and any other information the Bureau evaluator believes is
important concerning Bureau policy and the application of
sentencing guidelines issued by the Sentencing Commission. Since
the determination of a sentence under the guidelines is the
province of the Court, recommendations ordinarily focus on
identifying psychological or psychiatric factors pertinent to the
sentencing guidelines to help the Court make its determination.
Examples of factors for consideration include, but are not
limited to:
# Diminished Capacity as defined by the Sentencing Commission
Guidelines.
# Mitigating and aggravating factors in the form of mental or
behavioral disorders.
# Unusual characteristics of the defendant.
# Additional information that may affect the application of
guidelines.
Recommendations provided in the evaluation shall not specifically
address or make recommendations as to numerical calculations or
recalculations of sentencing guideline elements.
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The results of the evaluation are to be furnished to the
referring court within 60 days, unless the court grants an
extension for further study. An extension may not exceed an
additional 60 days.
a. Designation. Designations will be completed as outlined in
Chapter 3, Security Designation Procedures for New Commitments,
of Program Statement 5100.07, Security Designation and Custody
Classification Manual. Designation may be made to any Bureau
facility as long as this meets statutory requirements and the
facility has the resources necessary to meet the needs of the
inmate.
Following the designation, the Designation and Sentence
Computation Center (DSCC) shall forward to the institution all
available documents that may include, but are not limited to:
# Judgment in a Criminal Case (J&C), referral letter and
essential background information (e.g., copies of previous
evaluations), and Statement of Reasons (SOR).
# Pre-sentence/Post-sentence Report.
# Pretrial Services Report.
# Other relevant information provided in written form by
family, friends, or supervisors.
# Written communication to institution staff about the
specific objectives of the study.
# The arrest report or any other law enforcement agency
reports pertaining to the instant offense.
This information is essential in completing the background
sections of psychological and psychiatric evaluations, as well as
giving an indication of the defendant's behavioral pattern in the
community.
If the inmate does not arrive within 15 days of designation, the
receiving institution should contact the DSCC for assistance.
The Warden will designate a staff member, ordinarily the Case
Management Coordinator, to be responsible for initiating such
contact, as necessary. The psychologist or psychiatrist assigned
the evaluation will be responsible for requesting extensions (see
Attachment A for an extension letter example), and monitoring
progress and due dates of the evaluation.
b. Evaluation Cases With Referral Questions. The primary
report prepared by the forensic evaluator is the psychological or
psychiatric evaluation (see the Forensic Evaluation Training
Manual for an example). Psychological evaluations will be
prepared by a licensed psychologist and psychiatric evaluations
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should be prepared by a licensed psychiatrist. Clinical interns
may be involved in the process, but their work will be closely
supervised by a licensed psychologist or licensed psychiatrist.
Other assessments that may be part of an evaluation include an
educational, medical, vocational, or other assessment prepared by
the appropriate discipline. The need for, and content of, such
assessments will depend on the objectives of the evaluation and
the nature of the court's questions. The psychologist or
psychiatrist responsible for completing the evaluation shall
summarize the consultants’ findings in the evaluation, or include
written consultations in their entirety. If written
consultations are included, the consultant(s) shall also sign the
evaluation, specifying which sections they authored.
c. Pre-Sentence Evaluation With No Referral Questions. When the
court has no specific referral questions for the evaluation, and
efforts to secure referral questions have been unsuccessful, the
Bureau will provide the court an evaluation that includes any
information the evaluator believes is pertinent to the factors
set forth in 18 U.S.C. § 3553(a). This may include:
# A description of the nature of the offense.
# Characteristics of the defendant.
# Risk of dangerousness and propensity of defendant to engage
in further criminal conduct.
# Needed education, vocational training, medical care, or
other treatment.
10. PRETRIAL AND POST-TRIAL FORENSIC EVALUATIONS
(a) Time Frames and extensions for evaluations are
statutorily governed. It is critical that these time limits be
adhered to strictly. These time frames and any allowable
extensions are stated in the United States Code Title 18 Crimes
and Criminal Procedures. For internal monitoring purposes the
evaluation reckoning period begins on the date the evaluation
case arrives at a Bureau forensic site.
Forensic sites should implement a procedure for notifying the
court of the date of arrival and to request reasonable
adjustments to and extensions in the forensic evaluation time
frames when necessary.
The final day of the evaluation is the day on which the Bureau
must be ready to relinquish the inmate’s custody. The U.S.
Marshals Service should be notified by a staff person, usually
the Case Management Coordinator, via the DSCC, to transport the
inmate within the last portion of the evaluation period.
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The standard for evaluation of competency to stand trial is found
at 18 U.S.C. § 4241 (a) and (d): “Whether the defendant is
presently suffering from a mental disease or defect rendering him
mentally incompetent to the extent that he is unable to
understand the nature and consequences of the proceedings against
him or to assist properly in his defense.”
The standard for evaluation of criminal responsibility is found
at 18 U.S.C. § 17: “It is an affirmative defense to a prosecution
under any Federal statute that, at the time of the commission of
the acts constituting the offense, the defendant, as a result of
a severe mental disease or defect, was unable to appreciate the
nature and quality or the wrongfulness of his acts. Mental
disease or defect does not otherwise constitute a defense.”
11. FORENSIC EVALUATION. Each evaluation completed pursuant to
Title 18 U.S.C. §§ 4241 through 4246, must, by law, contain the
following information according to the format outlined in Title
18 U.S.C. § 4247:
# Personal history and present symptoms.
# Description of all psychological, psychiatric, and
medical tests performed, as well as results.
# The evaluator’s findings.
# A current diagnosis in proper DSM multiaxial format.
# A prognosis.
# The evaluator’s opinion as to the specific questions
posed by the court.
The Psychology Services Administrator will provide guidance for
the standards and formats for forensic evaluations completed by
contract and forensic psychologists. The Medical Director will
provide guidance for the standards and formats for forensic
evaluations completed by contract and forensic psychiatrists.
Evaluators should only offer opinions on the issues specifically
raised by the court. In some instances, court orders may cite
certain statutes, yet the text of the order may refer to other
issues. Whenever the actual intent of the court is unclear, the
forensic evaluator will contact the Clerk or the attorneys
(assistant U.S. attorney and defense counsel)assigned to the case
for clarification before preparing an evaluation.
12. FORENSIC SITES. The Correctional Programs Division and
Health Services Division will identify certain institutions as
forensic sites. Cases committed to the custody of the Attorney
General for evaluation under Title 18 U.S.C. §§ 4242 - 4247 will
be designated as noted in section 7 of this Program Statement.
Generally, only those inmates requiring hospitalization by
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statute (§4241(d), §4243(e), §4245, §4246(e)) or clinical
condition will be designated to a Medical Referral Center (MRC).
All other inmates will be designated to non-MRC forensic sites.
13. FORENSIC EVALUATOR QUALIFICATIONS. Federal law stipulates
that only licensed psychologists or licensed psychiatrists can
perform forensic evaluations ordered pursuant to Chapter 313,
Title 18 U.S.C. §§ 4241-4246. The Bureau encourages
participation by pre-doctoral psychology interns, post-doctoral
fellows, psychiatric residents, and persons pursuing licensure in
the forensic process. However, it is critical that an
appropriately licensed psychologist/psychiatrist take full
responsibility for the final product and opinion. This person
must be fully involved in all aspects of the evaluation and be
prepared to testify if called.
The possibility always exists that persons other than the
licensed psychologist/psychiatrist could be subpoenaed. However,
at no time should they be portrayed as the primary evaluator, nor
should attorneys ever be encouraged to subpoena them in lieu of
the primary evaluator.
14. EVALUATION SUPERVISION.
(a) FORENSIC EVALUATOR SUPERVISION AT FORENSIC SITES. All
forensic evaluations completed by staff psychiatrists, residents,
fellows, or contract psychiatrists will be reviewed by the
institution Chief Psychiatrist, where one is on staff, or, if no
Chief Psychiatrist is on staff, then by a supervisory staff
clinician designated by the Medical Director. The reviewing
Chief Psychiatrist or supervisory staff clinician will co-sign
the evaluation of any non-licensed psychiatrist prior to filing
with the court. The reviewing Chief Psychiatrist or supervisory
staff clinician must review, at minimum, 10 percent of the
forensic evaluations completed by a forensic psychiatrist. A
documented system of control must be in place to ensure the
sample of evaluations and accompanying data have been reviewed.
The Chief Psychiatrist or supervising staff clinician must sign a
review memorandum to acknowledge that all information in the
forensic file is complete and the evaluation follows the
statutory guidelines and answers the court’s questions.
The Chief Psychologist must review, at minimum, 10 percent of the
evaluations of all forensic psychologists. A documented system
of control must be in place to ensure the sample of evaluations
and accompanying data have been reviewed. The Chief Psychologist
must sign a review memorandum to acknowledge that all information
in the forensic file is complete and the evaluation follows the
statutory guidelines and answers the court’s questions.
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The Chief Psychologist, or a designated licensed psychologist,
must review and co-sign every evaluation prepared by psychology
students, pre-doctoral interns, post-doctoral fellows/residents,
or any consultant or contractor. The Chief Psychologist is also
required to review and co-sign all evaluations written by any new
forensic psychologist until such time as the Chief Psychologist
believes this staff member is fully aware of, and responsible
for, following Bureau policy and training guidelines. Typically,
this intensive review of the new evaluator’s work will last one
year. The Chief Psychologist must sign all evaluations completed
by non-forensic psychologists. In addition, contacts related to
the forensic evaluation at outpatient study sites should be
documented in a log (see Attachment B - Sample Contact Log).
(b) FORENSIC EVALUATOR SUPERVISION AT MRCs. At MRCs, the
evaluation supervision process can be shared with another
supervisory psychologist as long as the Chief Psychologist can
assure policy and best practices are followed. At MRCs, the
medical record and Psychological Data System (PDS) serves as the
official, chronological record of services provided.
15. MANAGING THE EVALUATION. The Warden shall assign the
evaluation to a staff member, ordinarily an Associate Warden or
Psychologist, who is responsible for:
# Ensuring quality control.
# Ensuring timely completion of the study.
# Ensuring the standards specified by policy have been
satisfied.
# Ensuring the court's objectives have been met.
# Preparing the final transmittal letter to the court.
# Notifying the U.S. Marshal and the DSCC that the inmate
is ready for return to court.
Once the evaluation is completed, the Warden signs the
transmittal letter and forwards it and the original evaluation to
the Court. Closely examine the Court Order to determine if
copies of the evaluation are to be provided directly to the
attorneys, the Office of United States Probation, or the Clerk of
the Court. Where these issues are not specifically addressed,
provide the original and two additional copies of the evaluation
to the Court. General guidelines for a transmittal letter are
specified in Attachment C.
All correspondence addressed to a Federal Court shall include the
inmate's register number and docket number(s) pertinent to the
inquiry.
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A summary of clinically relevant information from each forensic
evaluation will be entered by the forensic evaluator (or a
designee) in PDS at the conclusion of the study. This will
include:
# A diagnosis.
# A summary of psychological test results.
# A summary of mental health history, including any incidence
of treatment.
16. CONFIDENTIALITY. Prior to the initial interview, the
forensic evaluator must inform the inmate about the limits to
confidentiality that exist in a forensic evaluation. The nature
of the evaluation and questions raised by the Court must also be
explained. The inmate will be told that all things learned from
him or her or about him or her may be included in an evaluation
to the Court. The inmate will also be informed that staff may be
subpoenaed to testify at a later hearing regarding the
evaluation. The issue of the confidentiality warning must be
documented in the final report.
Conducting telephone interviews with family members, arresting
officers, or others with valuable information is encouraged.
However, prior to such an interview, these persons must also be
informed of the nature of the study and lack of confidentiality
described above.
17. PROFESSIONAL ROLE RESPONSIBILITIES. Bureau psychologists and
psychiatrists conduct forensic evaluations directly for the
Federal Court, not for the U.S. Attorney or for the defense.
Evaluators must strive to be thorough, unbiased, and to use
reasoning that comports with a consensus of professional
judgement. Neither attorney will be given a final opinion on a
forensic issue prior to the court being notified.
Individuals engaged in forensic work should be familiar with the
ethical guidelines applicable to their professions. The ethical
guidelines published by the American Psychological Association,
the American Psychiatric Association, and the American Academy of
Psychiatry and the Law should be consulted and clinical
supervision should be sought when potential ethical conflicts
arise.
Professional ethics dictate that psychologists completing
forensic evaluations make every effort to avoid role conflicts.
Whenever possible, the forensic evaluator should not be the
person providing therapy or otherwise overseeing the treatment of
the person being evaluated. However, in some situations such as
crisis intervention the evaluator may find it necessary to
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provide time-limited treatment to the person being evaluated. In
addition, at MRCs the utilization of a team approach may make the
distinction between treatment and evaluation roles less easily
separated. In these circumstances, the evaluator may belong to a
team which is expected to both evaluate and have some role in
treatment.
18. DISCIPLINARY CASES/REPORTS.
(a) Study Inmates. In order to avoid dual role conflicts,
when a study inmate incurs a disciplinary report, the need for
evaluation of competency or responsibility may arise. If this
occurs, it will be assigned by the Chief Psychologist to a
psychologist who is not the primary evaluator for an opinion of
competence or responsibility prior to initiating any disciplinary
procedures. The psychologist completing the disciplinary
evaluation should consult with the forensic evaluator assigned to
the court case to maintain consistency.
(b) Non-Study Inmates. If at any stage of the disciplinary
process an inmate appears to staff to be mentally ill, Unit
Discipline Committee (UDC) staff or the Discipline Hearing
Officer (DHO) will consult with psychology staff to determine if
an evaluation of competency or responsibility is warranted. If
warranted, the psychological evaluation is guided by both P.S.
5270.07 (Inmate Discipline and Special Housing Policy - Chapter
1, Page 2), and the standards for responsibility and competence
addressed in this Program Statement. It is important to note
that psychologists must make every effort to review all past
forensic evaluations on the individual in question and, when
relevant, mental health information from the person’s Pre-
Sentence Investigation (PSI). Although disciplinary evaluations
are not governed by statute, they follow the same general
standards as competency and responsibility (insanity)
evaluations, although they may need to be modified to fit the
disciplinary situation.
When completing an evaluation for disciplinary purposes, on
either a study inmate or a non-study inmate, use the abbreviated
report format in Attachment D.
19. EVALUATIONS FOR THE U.S. PAROLE COMMISSION. Requests for
psychological evaluations to help determine parole eligibility
may, on occasion, come from the U.S. Parole Commission (USPC),
the District of Columbia Parole Commission, and some State Parole
Commissions when a Federal inmate is serving concurrent state and
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Federal sentences. Most of these evaluations will fall under the
purview of Title 18 U.S.C § 4205. This statute was repealed
(along with others pertaining to parole) in 1987; however, some
inmates sentenced prior to 1987 (“old law”) may be eligible for
parole. The statute allows for the USPC to receive an evaluation
from the Bureau on an inmate’s suitability for parole, including
mental and physical health, criminal record, and social
background.
On occasion, the USPC will ask for predictions about future
criminal and/or dangerous behavior. Predictions regarding such
acts under specific circumstance should be qualified and
appropriate disclaimers given, for example:
“The following information concerning the inmate’s behavior
and possible future behavior are based upon the inmate’s
self-report, test responses, and other information for which
the reliability may be unknown. There are no consistent
means by which to accurately predict an individual’s future
behavior. Some accuracy, however, has been demonstrated by
considering past behavior patterns in combination with
demographic, personal and possible precipitating factors in
conjunction with psychological assessment data.”
These evaluations will be in accordance with the Freedom of
Information Act/Privacy Act (FOIA/PA). The format to be used in
preparing these reports should be similar to the one presented in
the training manual “How to Conduct a Thorough and Professional
Forensics Evaluation.”
20. EVALUATIONS FOR THE WITNESS SECURITY PROGRAM. 18 U.S.C.
§ 3521(c) requires the Attorney General to obtain and evaluate
all available information regarding the suitability of any person
seeking admission into the Federal Government’s Witness Security
Program. A psychological evaluation is required as part of this
assessment process.
Bureau psychologists have been designated to perform these
evaluations. These psychologists work under the supervision of
the Chief, Psychological Evaluation Section, Psychology Services
Branch, Central Office, or his/her designee.
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21. RECORDS RETENTION. Requirements and retention guidance for
records and information applicable to this program are available
in the Records and Information Disposition Schedule (RIDS) system
in BOPDOCS and Sallyport. Information created by this program is
also governed by all applicable FOIA/PA laws and regulations.
/s/
Harley G. Lappin
Director
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Attachment A
EXAMPLE
Date (fill in)
The Honorable______________
United States District Court
Western District Of Missouri St. Joseph Division
6672 Charles Evans Whittaker United States Court House
400 East 9 Streetth
Kansas City, Missouri 64106
Re:
Reg. No. __________
Case No. __________
Dear Judge _____:
Your Court Order dated fill in date here committed Mr. X to the custody of the Attorney
General for a mental health evaluation pursuant to Title 18, United States Code, Section 4241.
The provisions of this statute permit commitment to the custody of the Attorney General for 30
days.
Mr. X arrived at fill in name of institution on date. He would normally be approved for a
return to court on approximately date. However, fill in the reason why an extension is
necessary. Given this new development, we are respectfully requesting a 15-day extension.
In accordance with Title 18, United States Code, Section 4241, the Court may grant an additional
15-day period of time to complete the mental health evaluation. If the extension is granted, the
evaluation will be completed on or about date, and a written report will be submitted to the
Court. If the mental health evaluation is completed prior to the projected completion date, the
Court will be notified. If you have any questions or concerns about the proposed extension or the
details of the case, please contact me at number.
Sincerely,
Name of Warden,
WARDEN
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Attachment A
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Attachment B
Inmate Name: “Sample Contact Log”
Register Number:
Inmate Contacts Attorney Contacts Collateral Contacts
Date, Time, Length
Brief Notes
Date, Time, Length
Brief Notes
Date, Time, Length
Brief Notes
Date, Time, Length
Brief Notes
Date, Time, Length
Brief Notes
Date, Time, Length
Brief Notes
Date, Time, Length
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Attachment C
U.S. DEPARTMENT OF JUSTICE
Federal Bureau of Prisons
GENERAL GUIDELINES FOR TRANSMITTAL LETTER
Paragraph 1:
This paragraph will state that we are forwarding two copies of
the evaluation. It will mention the date of the sentence, type
of sentence, the offense, arrival date at the facility, and the
date the case is due in court (to include any extension
information).
Paragraph 2 (and additional paragraphs, if needed):
This paragraph will briefly respond to the court's referral
questions, highlighting major findings. If no questions were
posed by the court, then summarize the findings of the clinical
evaluation and any pertinent information from the observation
process.
Final Paragraph:
Inform the court that we will provide any additional information
the court may need.
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Attachment D
U.S. DEPARTMENT OF JUSTICE Complete in PDS
Federal Bureau of Prisons
Mental Health Evaluation - “Institution Disciplinary Process”
Institution: Date:
Name of Inmate:
Register Number:
Name of Evaluator:
REASON FOR REFERRAL AND IDENTIFYING INFORMATION: (source, reason
for referral, identifying information)
BACKGROUND INFORMATION: (history of mental illness, psychological
or psychiatric treatment, prior forensic evaluation)
CLINICAL INTERVIEW AND MENTAL STATUS EXAM: (results of brief
clinical interview and mental status exam, note limits of
confidentiality discussed)
CLINICAL IMPRESSION: (diagnosis if rendered, basis for diagnosis)
FINDINGS: (conclusions based on general criteria for competence
and/or responsibility)
The following language may be helpful for explanation:
A person is not responsible for his conduct if, at the time of
the conduct, the person, as a result of a severe mental disease
or defect, was unable to appreciate the nature and quality or the
wrongfulness of his/her acts. Some key criteria:
# Diagnosable mental disorder or defect.
# Lacked mental capacity to realize that he/she committed a
wrong.
# Did not appreciate why his/her behavior or conduct was
wrong.
# Could not stop his/her behavior (“irresistible impulse”).
A person is incompetent if he/she lacks the ability to understand
the nature of the disciplinary proceedings, or to assist in
his/her defense at the proceedings. Some key criteria:
# Understanding of charges against him/her.
# Understanding of the disciplinary process/proceedings.
# Can they participate in his/her own defense?
(Note: File in Central File - FOI Exempt - Section 2)
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