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The Forensic

DOCUMENTATION

SOURCEBOOK

The Complete Paperwork Resource for

Forensic Mental Health Practice

SECOND EDITION

Theodore H. Blau

Fred L. Alberts, Jr.

John Wiley & Sons, Inc.

The Forensic

DOCUMENTATION

SOURCEBOOK

The Forensic

DOCUMENTATION

SOURCEBOOK

The Complete Paperwork Resource for

Forensic Mental Health Practice

SECOND EDITION

Theodore H. Blau

Fred L. Alberts, Jr.

John Wiley & Sons, Inc.

This book is printed on acid-free paper.

Copyright © 2004 by John Wiley & Sons, Inc. All rights reserved.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey.

Published simultaneously in Canada.

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ISBN 0-471-68288-8

Printed in the United States of America.

10 9 8 7 6 5 4 3 2 1

To Dr. Theodore H. Blau (1928–2003) whose intellect, generosity, and gracious presence is greatly missed.

Contents

CD Contents ............................................................ xv

Acknowledgments .................................................... xix

Introduction ............................................................ xxi

Chapter 1 Initiating Forms .......................................... 1.1

Form 1 Forensic Intake

Sample Form ............................................................................... 1.6

Example of Completed Form ................................................................ 1.7

Form 2 Charge Sheet

Sample Form ............................................................................... 1.8

Example of Completed Form ................................................................ 1.9

Form 3 Terms of Agreement Letter

Sample Form .............................................................................. 1.10

Form 4 Terms of Engagement Contract

Sample Form .............................................................................. 1.11

Form 5 Case Chronology

Sample Form .............................................................................. 1.13

Example of Completed Form ............................................................... 1.14

Form 6 Case Material Received

Sample Form .............................................................................. 1.15

Example of Completed Form ............................................................... 1.16

Form 7 Case Materials Sent

Sample Form .............................................................................. 1.17

Example of Completed Form ............................................................... 1.18

Form 8 Forensic Intake Sheet (Pre-Examination)

Sample Form .............................................................................. 1.19

Example of Completed Form ............................................................... 1.20

Form 9 Preselection Interview Form

Sample Form .............................................................................. 1.21

vii

Contents

Chapter 2 Initiating the Assessment Process .................... 2.1

Form 10 Background Summary—From Record Review

Sample Form ............................................................................... 2.4

Example of Completed Form ................................................................ 2.5

Chapter 3 Initiating a Forensic Evaluation ........................ 3.1

Form 11 Apprisal of Rights

Sample Form ............................................................................... 3.5

Example of Completed Form ................................................................ 3.6

Sample of Spanish Language Form (Aviso de Derechos) ...................................... 3.7

Form 12 Authorization for Release of Psychological Information

Sample Form ............................................................................... 3.8

Example of Completed Form ................................................................ 3.9

Form 13 Authorization for Release or Receipt of Information

Sample Form .............................................................................. 3.10

Form 14 Psychological Evaluation Informed Consent

Sample Form .............................................................................. 3.11

Chapter 4 Process Forms .......................................... 4.1

Form 15 Informed Consent—Child Custody/Visitation Evaluation

Sample Form .............................................................................. 4.22

Example of Completed Form ............................................................... 4.23

Form 16 Informed Consent—Custody and Visitation Evaluation

Sample Form .............................................................................. 4.24

Example of Completed Form ................................................................ 4.25

Form 17 Informed Consent—Release of Records

Sample Form ............................................................................... 4.26

Form 18 Informed Consent

Sample Form .............................................................................. 4.27

Form 19 Authorization for Release of Psychological Information

Sample Form .............................................................................. 4.28

Form 20 HIPAA Compliant Protected Health Information Disclosure

Authorization

Sample Form .............................................................................. 4.29

Form 21 Permission to Release Confidential Records

Sample Form .............................................................................. 4.30

Form 22 Family History—Child

Sample Form .............................................................................. 4.31

Example of Completed Form ............................................................... 4.34

Form 23 Adult History

Sample Form .............................................................................. 4.37

Example of Completed Form ............................................................... 4.39

viii

Contents

Form 24 Test Room Schedule

Sample Form .............................................................................. 4.41

Example of Completed Form ............................................................... 4.43

Form 25 Family Conference

Sample Form .............................................................................. 4.45

Example of Completed Form ............................................................... 4.46

Form 26 Neuropsychological Symptom/Sign/Course

Sample Form .............................................................................. 4.47

Example of Completed Form ............................................................... 4.48

Form 27 Posttraumatic Stress Disorder

Sample Form .............................................................................. 4.49

Form 28 Drug Use History

Sample Form .............................................................................. 4.52

Example of Completed Form ............................................................... 4.53

Form 29 Medications

Sample Form .............................................................................. 4.54

Form 30 Clinical Observations

Sample Form .............................................................................. 4.55

Example of Completed Form ............................................................... 4.56

Form 31 Assessment Time Log

Sample Form .............................................................................. 4.57

Example of Completed Form ............................................................... 4.58

Form 32 Behavioral Symptomatology of Borderline Personality

Sample Form .............................................................................. 4.59

Form 33 Glasgow Coma Scale and Trauma Score

Sample Form .............................................................................. 4.60

Form 34 Items Frequently Used to Assess Mental Status in

Dementing Patients

Sample Form .............................................................................. 4.61

Form 35 Competency Evaluation Instrument

Sample Form .............................................................................. 4.62

Form 36 Insanity Defense Evaluation

Sample Form .............................................................................. 4.63

Form 37 Reporting Sanity and Competence Findings

Sample Form .............................................................................. 4.64

Form 38 Institutional Cost Survey

Sample Form .............................................................................. 4.65

Example of Completed Form ............................................................... 4.66

Form 39 Clinical Procedures Note

Sample Form .............................................................................. 4.67

Form 40 Limits of Confidentiality

Sample Form .............................................................................. 4.68

Form 41 Follow-Up Contacts

Sample Form .............................................................................. 4.69

ix

Contents

Form 42 Wechsler Scales—Comparison Sheet

Sample Form .............................................................................. 4.70

Example of Completed Form ............................................................... 4.71

Form 43 Wechsler Scales for Children—Comparison Sheet

Sample Form .............................................................................. 4.72

Example of Completed Form ............................................................... 4.73

Form 44 Achievement Tests Comparison Sheet

Sample Form .............................................................................. 4.74

Example of Completed Form ............................................................... 4.75

Form 45 Testing Comparison Sheet—Wechsler Scales

Sample Form .............................................................................. 4.76

Form 46 Psychological Autopsy Face Sheet

Sample Form .............................................................................. 4.77

Example of Completed Form ............................................................... 4.78

Form 47 Evaluation of Pre-Terminal Month—Psychological Autopsy

Sample Form .............................................................................. 4.79

Example of Completed Form ............................................................... 4.80

Form 48 Psychological Autopsy Interview

Sample Form .............................................................................. 4.81

Form 49 Final Form for Psychological Autopsy

Sample Form .............................................................................. 4.82

Example of Completed Form ............................................................... 4.83

Form 50 Visitation Questionnaire

Sample Form .............................................................................. 4.84

Example of Completed Form ............................................................... 4.85

Form 51 The Best Interests of the Child—Parent Evaluation

Worksheet

Sample Form .............................................................................. 4.86

Example of Completed Form ............................................................... 4.87

Form 52 The Best Interests of the Child—Workup Sheet

Sample Form .............................................................................. 4.88

Example of Completed Form ............................................................... 4.89

Form 53 The Best Interests of the Child

Sample Form .............................................................................. 4.90

Example of Completed Form ............................................................... 4.91

Form 54 Meeting the Best Interests of the Children: Parental

Summary

Sample Form .............................................................................. 4.92

Example of Completed Form ............................................................... 4.93

Form 55 Visitation Plan Outline

Sample Form .............................................................................. 4.94

Form 56 Standard Paragraphs for Custody or Visitation Plan

Sample Form .............................................................................. 4.95

Form 57 Wisconsin Card Sort

Sample Form .............................................................................. 4.96

Example of Completed Form ............................................................... 4.97

x

Contents

Form 58 Trials A and B

Sample Form .............................................................................. 4.98

Example of Completed Form ............................................................... 4.99

Form 59 Hand Dynamometer

Sample Form ............................................................................. 4.100

Example of Completed Form .............................................................. 4.101

Form 60 Formulae and Worksheet for Estimating Premorbid

WAIS-R Scores

Sample Formulae Form ................................................................... 4.102

Sample Worksheet Form .................................................................. 4.103

Form 61 MMPI-2 Comparison

Sample Form ............................................................................. 4.104

Form 62 Probability of Malingering Checklist

Sample Form ............................................................................. 4.105

Form 63 Factors That Increase Potential Incredibility and Distortion

in the Testimony of Children

Sample Form ............................................................................. 4.106

Form 64 Scoring Sheet for Detecting Malingering on the Booklet

Category Test

Sample Form ............................................................................. 4.107

Example of Completed Form .............................................................. 4.108

Form 65 Scoring Sheet for Detection of Malingering on the Luria￾Nebraska Neuropsychological Battery

Sample Form ............................................................................. 4.109

Example of Completed Form .............................................................. 4.110

Form 66 Scoring Sheet for the Identification of Malingered Head

Injury on the Wechsler Adult Intelligence Scale—Revised

Sample Form ............................................................................. 4.111

Example of Completed Form .............................................................. 4.112

Form 67 A Malingering Index for the Wechsler Memory

Scale—Revised

Sample Form ............................................................................. 4.113

Example of Completed Form .............................................................. 4.114

Form 68 Lees-Haley Fake Bad Scale (FBS) for the MMPI-2

Sample Form ............................................................................. 4.115

Example of Completed Form .............................................................. 4.116

Form 69 Invalidity/Fake Bad/Exaggeration/Malingering Profile

Sample Form ............................................................................. 4.117

Example of Completed Form .............................................................. 4.118

Chapter 5 Forms for Deposition and Trial Preparation .......... 5.1

Form 70 Depositions and Court Appearances

Sample Form ............................................................................... 5.5

Example of Completed Form ................................................................ 5.6

xi

Contents

Form 71 Distribution of Forensic Cases

Sample Form ............................................................................... 5.7

Example of Completed Form ................................................................ 5.8

Form 72 Time Distribution

Sample Form ............................................................................... 5.9

Example of Completed Form ............................................................... 5.10

Form 73 Deposition and Conference Record

Sample Form .............................................................................. 5.11

Example of Completed Form ............................................................... 5.12

Form 74 Rules of the Road for the Expert Witness at Trial

Sample Form .............................................................................. 5.13

Form 75 Day in Court Checklist

Sample Form .............................................................................. 5.14

Chapter 6 Forms for Family Law Consultation ................... 6.1

Form 76 Parental Concordance about Child’s Adaptation

Sample Form ............................................................................... 6.6

Example of Completed Form ................................................................ 6.7

Form 77 Evaluation of Credibility Assessment

Sample Form ............................................................................... 6.8

Example of Completed Form ................................................................ 6.9

Form 78 Parental Like/Don’t Like Identifications

Sample Form .............................................................................. 6.10

Example of Completed Form ............................................................... 6.13

Form 79 Parental Like/Don’t Like Identifications

Sample Form .............................................................................. 6.16

Example of Completed Form ............................................................... 6.20

Form 80 Discipline Style Checklist

Sample Form .............................................................................. 6.24

Example of Completed Form by Father ..................................................... 6.26

Example of Completed Form by Mother .................................................... 6.28

Form 81 How Do Your Parents Discipline You?

Sample Form .............................................................................. 6.30

Example of Completed Form ............................................................... 6.31

Form 82 Collateral Interview

Sample Form .............................................................................. 6.32

Example of Completed Form ............................................................... 6.33

Form 83 General Recommendations

Sample Form .............................................................................. 6.34

Chapter 7 Forms for Neuropsychological Assessment ......... 7.1

Form 84 The Rancho Scale

Sample Form ............................................................................... 7.8

xii

Contents

Form 85 Malingering of Head Trauma Symptoms on Halstead-

Reitan Subtests

Sample Form ............................................................................... 7.9

Form 86 Detecting “Fake Bad” of Cognitive Impairment

on the Category Test

Sample Form .............................................................................. 7.10

Form 87 Malingering and the WAIS-III

Sample Form .............................................................................. 7.11

Example of Completed Form ............................................................... 7.12

Form 88 Infrequency—Psychopathology Scale

Sample Form .............................................................................. 7.13

Form 89 Identification of “Faking Good” and “Faking Bad”

(F-K Normative Data)

Sample Form .............................................................................. 7.14

Form 90 Symptoms Claimed/Observed

Sample Form .............................................................................. 7.15

Example of Completed Form ............................................................... 7.16

Form 91 Detection of Malingering of Personality Pathology

on the Psychopathic Personality Inventory

Sample Form .............................................................................. 7.17

Form 92 Frontal Lobe Personality Scale

Sample Form .............................................................................. 7.18

Form 93 Summary of Brain-Behavior Deficits Found through

Neuropsychological Evaluation

Sample Form .............................................................................. 7.19

Example of Completed Form ............................................................... 7.20

Chapter 8 Miscellaneous Forms ................................... 8.1

Form 94 Notice That Test Materials Require Qualified Reviewer

Sample Form ............................................................................... 8.8

Form 95 Cover Letter—Raw Data Not Released

Sample Form ............................................................................... 8.9

Form 96 Request for Records by Nonpsychologists

(Forensic)—Ethical Guidelines

Sample Form .............................................................................. 8.10

Form 97 Attorney’s Presence during Psychological Examination

Sample Form .............................................................................. 8.11

Form 98 Videotaping during Testing

Sample Form .............................................................................. 8.12

Form 99 Memorandum of Understanding

Sample Form .............................................................................. 8.13

Example of Completed Form ............................................................... 8.14

Form 100 Cast Study Enquiry

Sample Form .............................................................................. 8.15

Example of Completed Form ............................................................... 8.16

xiii