A general interview outline.
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DATE(S):
TO
RE:
Case No.
Dear
Pursuant to request, a psycho-legal examination was conducted upon ***** regarding the following questions:
I. QUESTIONS BEFORE THIS EXAMINATION:
1.
2.
3.
II. PERSONAL IDENTIFYING INFORMATION:
NAME:
BIRTH DATE: AGE: PHONE:
GENDER: MARITAL STATUS:
CHILDREN:
ADDRESS:
ETHNICITY: LANGUAGE:
Nat Amer African Amer Hispanic Asian Hindu Caucas Other
III. CASE IDENTIFYING INFORMATION:
COURT CASE NO.:
ATTORNEY: COUNTY:
SOCIAL WORKER:
CHILDREN IN CASE:
DATE CHILDREN REMOVED:
VICTIM INFORMATION:
NEXT COURT DATE:
IV. EXAMINATION PROCESS INFORMATION:
EXAM DATE(S): EXAM PLACE:
EXAM INSTRUMENTS:
RIGHTS GIVEN BEFORE INTERVIEW BEGINS: Yes No
PICTURE IDENTIFICATION CONFIRMATION: Yes No
PSYCHOLOGICAL OPINION
V. OPINIONS REGARDING QUESTIONS BEFORE THIS EXAMINATION:
1.
2.
3.
VI. BASIS FOR OPINIONS BEFORE THIS EXAMINATION:
VII. REVIEW OF PRESENT PSYCHOLOGICAL SYSTEMS:
Depression:
Anxiety:
Mania:
Obsessions/Compulsions:
Psychosis:
Fears/Worry:
PTSD:
ADHD/ADD:
Oppositional/Defiant:
Conduct/Behavior Problems:
Constitution:
Nutritional Status:
PAIN (Organic or Psychological):
Current Psychiatric Medications:
Etiology of Current Psychiatric/Psychological Problem(s):
VIII. DIAGNOSTIC IMPRESSION:
DSM-5: ICD-10:
DATA BASIC TO PSYCHOLOGICAL OPINION
IX. PAST REPORTS AND OTHER DATA REVIEWED:
X. SUICIDE/HOMICIDE RISK ASSESSMENT:
1. Patient/Defendant Statements:
2. Suicide Risk Factors:
3. Homicide Risk Factors:
4. Protective Factors:
5. Examiner Opinion:
XI. TREATMENT NEEDS:
XII. PERTINENT BACKGROUND INFORMATION:
A. Childhood/Developmental History:
1-family data
2-parents
3-development
4-friends
5-sweethearts
6-trauma/rejection
7-foster/CPS
8-live with
extended family
9-Parents
10-Cohesion
B. Adulthood/Relationship History:
1-social/loner
2-# marriage
how began
length
problems (drugs, DV, sex, kids)
3-#divorce-why split
4-#relationships
5-CPS/legal
6-abode preference
7-parenting
8-parenting after divorce
9-co-parenting
C. Educational History:
1-completed
2-LD, spec ed
3-GPA-hs/coll
4-interest
5-behav prob
6-# schools
7-popularity
8-post hi-school
D. Substance Use History:
Tobacco:
Caffeine:
Alcohol:
Illegal Drugs:
coke/crank
meth/crank
marijuana
synthetics
heroine/opiates
LSD, Mushrooms
peyote
dust
ecstasy/date
huffing
Began–
Clean date–
OTC:
Other people’s medication:
E. Vocational/Financial Support History:
1-voc training
2-current job
begin-end
3-prior jobs
begin-end
4-injury/WC
5-SSI?
6-welfare/family support
F. Military History:
1-branch/duties
2-in/out
3-discharge
4-stations
5-rank
6-NJP/Ct marshal
G. Medical History:
1-health
child/adult
2-disease/defects
3-hospitalizati
4-surgeries
5-accidents
6-broken bones
Head Injury/TBI:
Appetite/Weight:
Exercise:
Sleep:
Current Medications:
Vitamins:
Supplements:
H. Mental Health History:
1-previous dx
2-hospitalizat
where/duration/reason
3-medications
4-treatment
individual
group
rehab progress
educational
I. Assault/Abuse/Social Mistreatment History:
1-bully/harassment
2-physical
3-sexual
4-violence
5-DV
6-perpetrator
J. Spirituality:
1-organized
2-self
K. Habits/Interests:
L. Sexual History:
1-1st message
2-affection-home/other
3-1st sex experience
4-masturbatory images
5-activity/frequency
6-dysfunction
7-child porn
8-child contact
9-own molest
10-sex trouble/accused
11-legal problems
12-lit/media porn
13- bondage
14-ritual
15-internet use
16-family hx problems
17-prior sex tx
Pre-Adolescent:
Adolescent:
Adult:
Pornography:
M. Legal History:
1-property
2-people
3-single/repeat
4-chronology
5-incarceration?
6-CPS
7-ADW
8-Weapons
0-Sexual
Juvenile:
Adult:
Felony:
Prison:
X. PRESENT PSYCHOLOGICAL STATUS:
A. Behavioral Description:
1-groom
2-attire
3-orientation
4-attitude
5-cooperatio
6-psychomot
7-speech
8-motivation
B. Thought Processes:
1-stream
productivity
continuity
language
2-content
preoccupation
environment
compulsion
obsessions
homicide/suicide
reference
3-disturbance
loose assn
tangential
flight
confusion
confabulation
word salad
depersonalization
4-concentratipm
C. Cognitive/intellectual Functioning:
1-Memory
registration
retention
recall
remote
recent
immediate
deficit
2-IQ
digit span
proverbs
3-cognitive
functioning
testing results
D. Judgment/Insight:
1-decision
making
2-reasoning
3-psychologically minded
self
others
E. Affective Processes:
1-mood
2-display
3-appropriate
4-gen affect
happy/sad
angry/hurt
up/down
5-prev prob
6-medication
7. Mood Disorder? YES NO
8. Swings? YES NO
9. Transient? YES NO
10. Substance related? YES NO
F. Perceptual Processes:
1-hallucinations
auditory
visual
kinetic
2-self perception
3-delusions
G. Impulse Control:
1-daily behavior
2-anger control
3-peo treatment
4-sex treatment/behave c partner
5-planning-any?
6-spontaneo
7. Anger management problem? YES NO
8. Conflict with others? YES NO
9. Gambling? YES NO
10. Talking? YES NO
11. Drinking? YES NO
12. Excessive use of anything?
H. Substance Use/Abuse:
1-alcohol
2-drugs
3-clean date
4-use sequence
5-social/solo
6-MAST
7-McAndrew
8. Current use? Amount? Frequency?
Alcohol
Cocaine/Crack
Meth/Crank
Marijuana
Synthetics
Heroin/Opiates
LSD, Mushrooms, Peyote
Ecstasy
Beauties, reds, yellow jackets, etc
Huffing-sniff glue, gas, paint, aerosols, Pam, helium, etc
Tobacco
Caffeine
OTC-diet pills, cough syrup, mouthwash, etc
Rx-person’s own, from other person
9. Use levels
Tolerance YES NO
Withdrawal YES NO
More taken or longer taken than intended YES NO
Desire to or unsuccessful efforts to cut down or control YES NO
Amount of time expended to obtain, use, or recover from effects ______________
Social, occupational, recreational activities significantly reduced YES NO
Substance continued despite knowledge it causing problems YES NO
I. Violence/Assaultive:
1-fights
2-arguments
3-DV
4-attitude
5-child treatment
6-history of
amount
types
verb/physical
weapon
impulse/planned
7. Self-injury, mutiliation?
8. Other injury-verbal, physical?
9. Provocation-self, other?
10. Blackout/forget assault after?
11. Remorse after or deserved?
12. Cycle-anger, assault, remorse, guilt, contrite, anger?
13. Build-up or sudden explosion?
XI. PSYCHOLOGICAL TESTING RESULTS:
A.
B.
XII. POTENTIAL FOR PSYCHOLOGICAL DISTORTION:
XIII. SUMMARY AND CONCLUSIONS: