Forensic Evaluation Juvenile CPT Code 99499 Modifier HA for Competency to Stand Trial Modifier TG for Treatment Amenability

New Mexico Interagency Behavioral Health Service Requirements and Utilization Guidelines Forensic Evaluation Juvenile CPT Code 99499 Modifier HA for Competency to Stand Trial Modifier TG for Treatment Amenability Initial 6-27-06, Rev 08-12-10 Service Definition: Juvenile Forensic Evaluations are appropriate for juveniles where there is an issue of the child s competency, or for any other juvenile where there is concern regarding mental illness, diminished cognitive abilities or severe learning disabilities that may adversely affect the child s comprehension of their legal situation. Competency is defined as the ability of a child to: understand the nature and possible consequence of charges, the trial process, the participants' roles, and the accused's rights in this process; participate with and meaningfully assist counsel in developing and presenting a defense; and make decisions to exercise or waive important rights. This evaluation is also appropriate for juveniles who may be exhibiting psychotic symptoms and who may require treatment to see if they can obtain competency. This evaluation of a juvenile is conducted to help the juvenile court with decision making about one of the following four psycho-legal issues: 1. Mental state at the time of the offense; 2. Competency to proceed through adjudication; 3. Amenability to treatment or rehabilitation as a child in available facilities, as defined in the New Mexico Children s Code under the Youthful Offender statute [32A-2-20, B. (1) and (2)]; 4. Treatment as an alternative to incarceration due to risk of harm to self and/or community. Source of Funding Target Population Program Requirements CYFD Juveniles involved with the juvenile justice system, age 11-18, where there is an issue of the child s competency, or for any other juvenile where there is concern regarding mental illness, diminished cognitive abilities or severe learning disabilities that may adversely affect the child s comprehension of their legal situation. Evaluations should be conducted in accordance with the ethical and professional standards contained in the American Psychological Association specialty guidelines for Forensic Psychologists. All Juvenile Forensic providers must use the designated and approved Juvenile Forensic Evaluation templates entitled either: 1. Forensic Evaluation for Children & Youth: Competency to Stand Trial, or 2. Forensic Evaluation for Children & Youth: Treatment Amenability 1

New Mexico Interagency Behavioral Health Service Requirements and Utilization Guidelines Provider Requirements Staffing Requirements Documentation Requirements All Forensic Competency To Stand Trial and Treatment Amenability Evaluations must include completion of each section and subsection of the identified templates and appropriate, intervention recommendations. Court testimony is included, if required. The completed evaluation will be returned to the referral source within (30) thirty calendar days from the date of the referral. In the event that the client is in a Juvenile Detention Center pending the results of the evaluation, the completed evaluation will be returned to the referral source within (15) fifteen calendar days from the date of the referral. Because of their special status as persons qualified as experts to the court, forensic evaluators have an obligation to maintain current knowledge of scientific, professional and legal developments within their area of claimed competence. They are obligated also to use that knowledge, consistent with accepted clinical and scientific standards. A New Mexico licensed psychologist or licensed psychiatrist with one year documented specialized experience in performing forensic evaluations, or; An individual licensed at the independent level holding a Master s Degree in Guidance and Counseling, Social Work, or Psychology and meets the following criteria: Relevant, documented training/experience in the utilization of the specific instrument(s) being administered. Training in interview techniques, including techniques directly related to forensic interviewing; and Under direct supervision by a New Mexico licensed psychologist or psychiatrist. Annual training and continuing education must be with the respective licensing act/board requirements. Forensic Evaluators must use the following: Rights and Responsibilities/Grievance Procedures Forms (signed acknowledgement) as applicable. Release of Information/Confidentiality Statement/Consent Forms (as applicable). Completed evaluation report (as outlined in Program Requirements above) labeled by type of evaluation, signed and dated by staff completing the report, and signed by supervisor (if applicable). Customer Satisfaction Survey Note 1: The evaluation report must be signed and dated by the supervisor, if completed by a Master s level provider. Note 2: Forensic evaluators have an obligation to document and be prepared to make available, subject to court order or the rules of evidence, all data that form the basis for their evidence or services. The standard to be applied to such documentation or recording anticipates that the detail and quality of such documentation will be subject to reasonable judicial scrutiny; this standard is higher than 2

New Mexico Interagency Behavioral Health Service Requirements and Utilization Guidelines the normative standard for general clinical practice. When forensic evaluators conduct an examination or engage in the treatment of a party to a legal proceeding, with foreknowledge that their professional services will be used in an adjudicative forum, they incur a special responsibility to provide the best documentation possible under the circumstances. Service Exclusions Admission/Service Criteria The juvenile forensic evaluation shall be done by court order only. Continuing Service Criteria Discharge Criteria Service Authorization Period Service Authorization Unit One completed forensic evaluation per client, per year. By product - Evaluation, report, and testimony, if required, for Competency to Stand Trial (HA modifier). By product - Evaluation, report and testimony, if required, for Treatment Amenability (TG modifier). Benefit Limits The juvenile forensic evaluation is intended to provide enough data on the legal issues to limit the necessity of testifying in court, although if called to testify, Expert Witness testimony is included in the rates. Rates are per the current fiscal year CYFD Fee Schedule. 3

Your Letterhead Goes Here Forensic Evaluation for Children & Youth Competency to Stand Trial TO: The Honorable Judge RE: Date of Birth: Children s Court #: Juvenile Probation (FACTS) #: Dates of Evaluation: Date of Report: CONFIDENTIAL REPORT This is a confidential report. It may not be released except as allowed or required by law, and as ordered by the Court. If release to the client and/or parent or guardian is allowed by law, we strongly recommend that this report not be provided to them without the knowledge of and in consultation with the evaluator, so that the results can be properly explained and any questions answered. Part I: PURPOSE AND PROCESS OF EVALUATION The children s court has ordered an evaluation of the youth named above to assist in determining the youth s competency to stand trial. When this question is raised, the court must consider whether the youth has sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding, and whether he has a rational as well as factual understanding of the proceedings against him. This evaluation is being provided to the Court pursuant to the Court s Order. Objectives of the Evaluation In order to assist the court in addressing this question, the present evaluation focused on obtaining information to form the following clinical opinions, based on the Dusky standard for competence applied in New Mexico: The youth s capacity to factually understand trial proceedings, their participants, and their purposes and outcomes

Name of Client Date of Birth Date of Report The youth s capacity to apply that understanding rationally to make decisions as a defendant 2 The youth s capacity to assist counsel in a defense To obtain information to reach these opinions, the examiner engaged in data collection focusing on the following efforts: To develop relevant biopsychosocial information about the youth To provide a description of the youth s current functioning and needs To examine functional abilities of the youth relevant for decisions based on the Dusky standard for competence applied in New Mexico. Notice of Limits of Confidentiality Prior to the evaluation, the youth and [ parent or guardian ] were informed about the purpose of the evaluation, the fact the evaluation was court ordered, and the evaluator s relationship to the court. The client and parent or guardian were informed of the limits of confidentiality, and that the evaluation will be provided to the youth s defense attorney, and may then be provided to other parties listed in the Court Order and as otherwise directed by the Court or allowed by law. Pursuant to HIPPA regulations, the client and [ parent or guardian ] signed Release(s) of Information to authorize the evaluator to access collateral sources of information obtained from other service providers. This information may or may not be in the public record. This report will not be used to establish guilt or innocence of the individual being evaluated. The client and parent or guardian were also informed that their participation was voluntary and that they had the right to refuse to answer any questions. They agreed to participate and appeared (to understand) (to not understand) this information, based on [ provide your reasoning ]. Method of Evaluation I interviewed the youth at [ location ] on [ date(s) ] for a total of [indicate number of hours]. I interviewed [name of parent or guardian] at [location] on [date(s)] for a total of [indicate number of hours]. Psychological Tests Administered (please refer to appendix for list of recommended tests)

Name of Client Date of Birth Date of Report 3 Part II: CLINICAL AND FORENSIC DATA NOTE: This section should include no opinions, interpretations or inferences. It should provide only facts, observations and data. The amount of detail to be obtained for Behavioral Health History need not be as great as in evaluations that focus on comprehensive treatment and rehabilitation plans. A. Identifying demographic information about youth B. Behavioral Health History 1. Early developmental history Family members, family situation during childhood Early developmental milestones 2. Educational history 3. Juvenile Justice history (arrests and adjudications) 4. Work/Vocational history 5. Mental Health History Family history of mental illness or developmental disability Disabilities (type, age at onset, degree of impairment) Medical history including medications Behavioral health treatment History C. Current Psychological Status 1. Mental Status Exam 2, Developmental status (cognitive, emotional, social) 3. Results of psychological tests administered (other than competence to stand trial instruments) 4. Assets/Resources of youth

Name of Client Date of Birth Date of Report 4 5. Diagnostic impression (DSM-IV Diagnosis) D. Interview Data Regarding Functional Abilities Associated with Competence to Stand Trial 1. Factual understanding of the criminal charges and courtroom Proceedings a. Comprehension of charges - To report the most serious charges to define or describe the charges, not necessarily using the legal terms; to gauge the seriousness of the charges b. Comprehension of Penalties c. Understanding of roles and of the adversarial nature of proceedings Understands that the judge is in charge in court, determines the verdict, determines sentencing Understands the defense attorney represents the defendant, plans defense, attempts to have the defendant found not guilty, and tries to minimize punishment Understands the prosecutor / Children s Court Attorney brings the charges, attempts to have the defendant found guilty, tries to maximize the punishment Understands what witnesses are and their role in a trial Understands what a jury is and that a minor could choose to have a jury trial d. Understanding of the concepts of evidence and proof e. Understanding of the concepts of pleas and plea bargain and their consequences Note: Minors lack of knowledge of these matters is not dispositive of the question of competence, if they have the capacity to learn them with simple instruction. Because this aspect of the Dusky standard is knowledge based, the evaluator must examine whether the youth is capable of learning about aspects of trials that the youth might not currently know. This is done by engaging in brief teaching of the youth on matters the youth does not understand, then assessing whether the youth was able to grasp and retain the information. If there is doubt about the minor s ability to retain the information once he or she has learned it, the evaluator may need to schedule another appointment to re-assess at least a few days later.

Name of Client Date of Birth Date of Report 5 2. Rational understanding of courtroom proceedings a. Presence or absence of unusual ideas or beliefs or self-defeating motivations, related to symptoms of behavioral disorders, when youth is asked about: Charges and possible penalties The roles of various participants in the trial, how the defendant might relate to them, and their effects on the defendant The trial process and evidence Best, worst and most likely outcomes of a trial Making a decision about a possible plea bargain b. Presence or absence of diminished capacity related to deficiencies in cognitive capacity, when youth is asked about matters listed in a above c. Presence or absence of poor judgment related to developmental immaturity, when youth is asked about matters listed in a above d. Evidence of past or potentially future psychotic, strange, or unmanageable courtroom behavior / potential for inappropriate courtroom participation 3. Ability to consult with counsel with a reasonable degree of rational Understanding a. Evidence of psychotic, irrational or unrealistic perceptions of defense counsel, and counsel s goals and expectations of defendant b. Evidence of impaired ability to agree / disagree with defense counsel, or to resolve conflicts with counsel c. Evidence of impaired ability to communicate with counsel, including ability to disclose pertinent facts, events and states of mind E. Data from Standardized, Normed Competence to Stand Trial Instrument (use of at least one is required) a. Instrument used (ECST-R, MacCAT-CA, or CAST-MR) b. Results of the instrument Description must include: Name and purpose of the tool, results

Name of Client Date of Birth Date of Report of the tool, and consistency with other reports and evaluations 6 Part III: CLINICAL IMPRESSIONS AND RECOMMENDATIONS NOTE: This section uses all available data in Clinical Data section to formulate impressions, interpretations, and explanations addressing the primary objectives of the evaluation. A. Clinical Summary Summary opinion regarding the youth s clinical, cognitive and developmental capacities and deficits B. Opinions about Competence to Stand Trial Abilities 1. Factual Understanding Opinion about the youth s capacity to factually understand trial proceedings, their participants, and their purposes and outcome Explanation of reasoning that supports this opinion 2. Rational Understanding and Decision Making Capacity The youth s capacity to apply information rationally to make decisions as a defendant Explanation of reasoning that supports this opinion 3. Assisting Counsel The youth s capacity to assist counsel in a defense Explanation of reasoning that supports this opinion 4. Explanation of causes of any deficits in the above abilities (e.g., specific mental disorder, developmental disability, developmental immaturity) C. Recommendations for Remediation if Likely to Be Found Incompetent 1. Intervention that would be required to remediate incapacities 2. Whether this will require hospitalization, or may be accomplished in a less restrictive setting

Name of Client Date of Birth Date of Report 3. Likelihood that efforts to remediate incapacities would succeed within the time allowed for restoring competence by New Mexico statute 7 Respectfully Submitted, Name Credentials

Name of Client Date of Birth Date of Report 8 APPENDIX: Checklists of Instruments and Methods Used ( Not to be sent with report. Keep in files with testing) Psychological Tests Used Achenbach System of Empirically Based Assessment (ASEBA) Adolescent Substance Abuse Subtle Screening Inventory - 2 (SASSI-A2) Adolescent Substance Abuse Subtle Screening Inventory - 3 (SASSI-A3) ASEBA Youth Self Report (YSR) Barkley ADHD Questionnaire Beck Depression Inventory-Version 2 (BDI-II) Child & Adolescent Functional Assessment Scale (CAFAS) Child Behavior Checklist (CBCL) Color Word Interference Test of the D-KEFS Jesness Inventory Revised (JI-R) Kiddie-Sads-Present and Lifetime Version (K-SADS-PL) Massachusetts Youth Screening Instrument-Version 2 (MAYSI-2) Millon Adolescent Clinical Inventory (MACI) Mini-Mental State Examination (MMSE) Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A) Neurobehavioral Cognitive Status Examination (NCSE) Personality Assessment Inventory (PAI) Repeatable Battery for Assessment of Neuropsychological Status (RBANS) Rorschach Projective Test Rotter Incomplete Sentences Blank (RISB) Scales of Independent Behavior Revised (SIB-R) Shipley-Institute of Living Scale (SILS) Symptom Checklist-90-R (SCL-90-R) Towers Test of Delis-Kaplan Executive Function System (D-KEFS) Vineland Adaptive Behavior Scales (VABS) Weschler Abbreviated Scale of Intelligence (WASI) Weschler Adult Intelligence Scale (WAIS-III) Weschler Intelligence Scale for Children IV (WISC-IV) Competency Assessment Instruments Used

Name of Client Date of Birth Date of Report Evaluation of Competency to Stand Trial Revised (ECST-R) MacArthur Competency Assessment Tool-Criminal Adjudication (MacCAT-CA) Competence Assessment for Standing Trial for Defendants with Mental Retardation (CAST-MR) 9 Collateral Sources Consulted Parent / Guardian / Primary Caretaker Juvenile Justice Probation & Parole CYFD Protective Services Detention Behavioral History Police Reports Medical Records from: Hospital Records from: School Records from: Cognitive / Intelligence Testing Records from: Developmental Disabilities Assessment Records from: Disability Determination Records from: Neurological Examination Records from: Neuropsychological Assessment from: Substance Use Testing Records from: Substance Use Treatment Records from: Admission / Discharge Records from: Out-patient Assessment / Treatment Records from: Sexual Offender Evaluation from: Functional Assessment from: COMPETENCY ASSESSMENTS ADMINSITERED Instrument Evaluation of Competency to Stand Trial Revised (ECST-R) Competency Assessment Instrument (CAI) Competence Assessment for Standing Trial for Defendants with Mental Retardation (CAST-MR) Juvenile Competency Quiz (JCQ)

Name of Client Date of Birth Date of Report 10

Name of Client Date of Birth Date of Report 11 PSYCHOLOGICAL INSTRUMENTS ADMINISTERED Instrument Achenbach System of Empirically Based Assessment (ASEBA) Adolescent Substance Abuse Subtle Screening Inventory - 2 (SASSI-A2) Adolescent Substance Abuse Subtle Screening Inventory - 3 (SASSI-A3) ASEBA Youth Self Report (YSR) Barkley ADHD Questionnaire Beck Depression Inventory-Version 2 (BDI-II) Child & Adolescent Functional Assessment Scale (CAFAS) Child Behavior Checklist (CBCL) Color Word Interference Test of the D-KEFS Jesness Inventory Revised (JI-R) Kiddie-Sads-Present and Lifetime Version (K-SADS-PL) Massachusetts Youth Screening Instrument-Version 2 (MAYSI-2) Millon Adolescent Clinical Inventory (MACI) Mini-Mental State Examination (MMSE) Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A) Neurobehavioral Cognitive Status Examination (NCSE) Personality Assessment Inventory (PAI) Repeatable Battery for Assessment of Neuropsychological Status (RBANS) Rorschach Projective Test Rotter Incomplete Sentences Blank (RISB) Scales of Independent Behavior Revised (SIB-R) Shipley-Institute of Living Scale (SILS) Symptom Checklist-90-R (SCL-90-R) Towers Test of Delis-Kaplan Executive Function System (D-KEFS) Weschler Abbreviated Scale of Intelligence (WASI) Weschler Adult Intelligence Scale (WAIS-III) Weschler Intelligence Scale for Children IV (WISC-IV) ADD VINELAND, OTHER DEVELOPMENTAL STATUS TOOLS

Name of Client Date of Birth Date of Report 12 COMPETENCY ASSESSMENTS ADMINSITERED Instrument Evaluation of Competency to Stand Trial Revised (ECST-R) Competency Assessment Instrument (CAI) Competence Assessment for Standing Trial for Defendants with Mental Retardation (CAST-MR) Juvenile Competency Quiz (JCQ) COLLATERAL SOURCES CONSULTED Source Parent / Guardian / Primary Caretaker Juvenile Justice Probation & Parole CYFD Protective Services Detention Behavioral History Police Reports Medical Records from: Hospital Records from: School Records from: Cognitive / Intelligence Testing Records from: Developmental Disabilities Assessment Records from: Disability Determination Records from: Neurological Examination Records from: Neuropsychological Assessment from: Substance Use Testing Records from: Substance Use Treatment Records from: Admission / Discharge Records from: Out-patient Assessment / Treatment Records from: Sexual Offender Evaluation from: Functional Assessment from:

CONFIDENTIALITY This report is confidential, and unless its release is in accord with the rules of criminal or civil procedure, the rules of evidence, pursuant to a Court Order or rule, or otherwise allowed by Federal or State law, it should not be released to anyone other then the Court. While the Juvenile may have a right to know the results of the evaluation, it is strongly recommended that this report not be provided to the client and/or parent or guardian without the knowledge of and consultation with the evaluator, so that the results can be properly explained and any questions or concerns answered. Criteria for Determining Competence to Stand Trial (1) The Client must have a factual understanding of the charges and proceedings, (2) the Client must also have a rational understanding of the charges and the proceedings, and (3) the Client must have the ability to assist his or her attorney. [State v. Rotherham, 122 N.M. 246, 252; 923 P.2d 1131, 1137 (1996)]." Disclosure of Limits of Confidentiality and Informed Consent Prior to the initiation of the evaluation, was informed about my role as a forensic evaluator, the purpose of the court-ordered evaluation, that his participation was voluntary, and that the information he provided may not be confidential. He was presented with the Statement of Rights form, which outlines the purpose of the evaluation, that the evaluation may not be confidential, that has the right to refuse to participate in the evaluation or answer specific questions despite the evaluation being court ordered, and the fact that in addition to his attorney, the report and/or information may be disclosed in the report and in Court to the Judge, the juvenile probation officer, and/or the Children s Court Attorney (also known as the District Attorney). This form was read and explained to. The defendant participated in a clinical interview and completed a variety of self-report psychological tests over the course of approximately minutes. The testing and clinical interview were conducted in an adequate environment and the results of the current evaluation are believed to represent a valid assessment of the defendant s current functioning and status.

Statement of Limits of Confidentiality and Informed Consent COURT-ORDERED JUVENILE FORENSIC EVALUATION I, have been ordered by the Children s Court to help Dr. answer one or more of the following issues: Competency to Stand Trial Treatment Amenability I understand I will be asked questions about my history and given psychological tests. Each test will be explained to me before it is given. Information collected for the Competency to Stand Trial evaluation will be written into a report and given to my defense attorney. Information collected for the Treatment Amenability evaluation will be written into a report and given to my defense attorney and the Court. I understand I may be asked about my current charges. Nothing I say that could be used to find me guilty can be included in eitherreport. I understand that I do not have to answer any or all questions asked of me. However, my defense attorney and the Judge will be told if I refuse to complete the evaluation. I understand the results of the Competency to Stand Trial evaluation are not confidential and will be shared with my defense attorney. A copy of the report may be given to the Judge, the juvenile probation officer, and the District Attorney. (The District Attorney is also known as the Children s Court Attorney.) The results of the Treatment Amenability evaluation will be shared with my defense attorney, the Judge, the juvenile probation officer, and the District Attorney. I understand that I have the right to know the results of the evaluation. However, my parents or I will not get a copy of the report. I also understand that any questions I have about the evaluation will be discussed with me at my request. I understand that threats of danger to myself or others will be reported to proper authorities, as required by law. I understand that some information about me will be given to ValueOptions and/or CYFD. This is for billing purposes only. ValueOptions will not be given a copy of the report. I understand these rights, have had any questions answered, and agree to this evaluation. Juvenile s Name Parent or Guardian (if present) Witness Date of Birth Today s Date Today s Date

Your Letterhead Goes Here Forensic Evaluation for Children & Youth TO: The Honorable Judge RE: Date of Birth: Children s Court #: Juvenile Probation (FACTS) #: Dates of Evaluation: Date of Report: Treatment Amenability CONFIDENTIAL REPORT This is a confidential report. It may not be released except as allowed or required by law, and as ordered by the Court. If release to the client or parent/guardian is allowed by law, we strongly recommend that this report not be provided to them without the knowledge of and in consultation with the evaluator, so that the results can be properly explained and any questions answered. Part I: PURPOSE AND PROCESS OF EVALUATION The children s court attorney has filed notice of intent to invoke an adult sentence for the youth named above. Under such circumstances and pursuant to 32A-2-20.B NMSA 1978, the court must consider whether the youth can be so sentenced, which requires that the court find: (a) that the child is not amenable to treatment or rehabilitation as a child in available facilities; and (b) the child is not eligible for commitment to an institution for children with developmental disabilities or mental disorders. This evaluation is being provided to the Court pursuant to the Court s Order. Objectives of the Evaluation In order to assist the court in addressing these issues, the present evaluation focused on obtaining information to form the following clinical opinions: Determination of willingness and ability of the youth to participate in treatment and rehabilitation in juvenile justice programs and facilities, consistent with public safety

Name of Client: Date of Birth: Date of Evaluation: 2 Determination of the availability of appropriate facilities that can address the youth s treatment and rehabilitation needs Determination of the youth s eligibility for commitment to an institution for children with developmental disabilities or mental disorders To obtain information to reach these opinions, the examiner engaged in data collection focusing on the following efforts: To develop a complete biopsychosocial history of the youth To provide a description of the youth s current functioning and needs To assess risk and protective factors related to potential for future violence and recidivism, and To examine characteristics of the youth associated with susceptibility or lack of susceptibility to successful treatment and rehabilitation in juvenile justice facilities and programs. Notice of Limits of Confidentiality Prior to the evaluation, the youth and [ parent or guardian ] were informed about the purpose of the evaluation, the fact the evaluation was court ordered, and the evaluator s relationship to the court. The client and parent or guardian were informed of the limits of confidentiality, and that the evaluation will be provided to the parties listed in the Court Order (i.e., the Court, the Children s Court Attorney, the Attorney for the Child, the Probation / Parole Officer) and as otherwise directed by the Court or allowed by law. Pursuant to HIPPA regulations, the client and [ parent or guardian ] signed Release(s) of Information to authorize the evaluator to access collateral sources of information obtained from other service providers. The client and parent or guardian were also informed that their participation was voluntary and that they had the right to refuse to answer any questions. They agreed to participate and appeared (to understand) (to not understand) this information, based on [ provide your reasoning ].

Name of Client: Date of Birth: Date of Evaluation: 3 Method of Evaluation I interviewed the youth at [ location ] on [ date(s) ] for a total of [indicate number of hours]. I interviewed [name of parent or guardian] at [location] on [date(s)] for a total of [indicate number of hours]. Psychological Tests Administered Part II: CLINICAL DATA NOTE: This section should include no opinions, interpretations or inferences. should provide only facts, observations and data. It A. Identifying demographic information about youth B. Behavioral Health History 1. Early developmental history Family members, family situation during childhood Early developmental milestones History of abuse, neglect, and/or trauma: Witness to domestic violence other trauma: Victim of other trauma; Closed head trauma and loss of consciousness; Other brain injury (hypoxic-ischemic brain injury; toxic-chemical brain injury); any significant hospitalizations, surgical/invasive procedures Involvement and outcome of Child Protective Services or comparable agency services 2. Educational history 3. Work/Vocational history 4. Mental Health History Family history of mental illness or developmental disability Disabilities (type, age at onset, degree of impairment) Medical history including medications Behavioral health treatment History C. Current Psychological Status 1. Mental Status Exam

Name of Client: Date of Birth: Date of Evaluation: 4 2. Results of psychological tests administered (other than risk tools) 3. Assets/Resources of youth 4. Diagnostic impression (DSM-IV Diagnosis) D. Risk Assessment 1. History and pattern of offenses 2. Description of features of the current adjudicated offense relevant to weigh for future risk of offending 3. Results of risk assessment tools (SAVRY, RSTI, YLS, or others) (use of at least one is required) Description must include: Name and purpose of the tool, results of the tool, and consistency with other reports and evaluations E. Other Information Relevant to Consider for Youth s Potential to Respond to Treatment and Rehabilitation Efforts 1. Response to past rehabilitation efforts Specific programs and placements Specific outcomes, and evidence that explains its success or failure 2. Data relevant for considering degree of youth s present motivation to respond to rehabilitation efforts Part III: CLINICAL IMPRESSIONS AND RECOMMENDATIONS NOTE: This section uses all available data in Clinical Data section to formulate impressions, interpretations, and explanations addressing the three primary objectives of the evaluation. A. Willingness/ability of youth to participate in treatment and rehabilitation in juvenile justice programs/facilities, consistent with public safety 1. Youth s rehabilitation needs

Name of Client: 5 Date of Birth: Date of Evaluation: Formulation of how youth would need to change in order to reduce likelihood of recidivism Description of data that support this opinion 2. Potential for Rehabilitation Formulation of opinion regarding youth s probable responsiveness to rehabilitation efforts Description of data that support this opinion 3. Risk to public safety Formulation of opinion about degree to which the youth presents a risk to public safety if rehabilitation attempted in juvenile programs Description of data that support this opinion B. Impressions regarding availability of juvenile justice facilities that can address the youth s treatment and rehabilitation needs 1. Identification of potential placement Description of juvenile justice program or facility that offers any potential for rehabilitation of this youth Description of data that support this opinion 2. Likelihood of rehabilitation Given youth s potential, and the above program or facility, opinion on the likelihood of rehabilitation within the time available Description of data that support this opinion C. Impressions regarding youth s eligibility for commitment to an institution for children with developmental disabilities/mental disorders 1. Diagnostic condition Whether the youth has a mental disorder or developmental disability that would require inpatient care Data supporting this opinion

Name of Client: Date of Birth: Date of Evaluation: 2. Commitment eligibility 6 If hospitalization is required, whether youth would meet other eligibility criteria for commitment to an inpatient facility for children Data that support this opinion Respectfully Submitted, Name Credential

Name of Client: Date of Birth: Date of Evaluation: 7 APPENDIX: Checklists of Instruments and Methods Used ( Not to be sent with report. Keep in files with testing) Psychological Tests Achenbach System of Empirically Based Assessment (ASEBA) Adolescent Substance Abuse Subtle Screening Inventory - 2 (SASSI-A2) Adolescent Substance Abuse Subtle Screening Inventory - 3 (SASSI-A3) ASEBA Youth Self Report (YSR) Barkley ADHD Questionnaire Beck Depression Inventory-Version 2 (BDI-II) Child & Adolescent Functional Assessment Scale (CAFAS) Child Behavior Checklist (CBCL) Color Word Interference Test of the D-KEFS Jesness Inventory Revised (JI-R) Kiddie-Sads-Present and Lifetime Version (K-SADS-PL) Massachusetts Youth Screening Instrument-Version 2 (MAYSI-2) Millon Adolescent Clinical Inventory (MACI) Mini-Mental State Examination (MMSE) Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A) Neurobehavioral Cognitive Status Examination (NCSE) Personality Assessment Inventory (PAI) Repeatable Battery for Assessment of Neuropsychological Status (RBANS) Rorschach Projective Test Rotter Incomplete Sentences Blank (RISB) Scales of Independent Behavior Revised (SIB-R) Shipley-Institute of Living Scale (SILS) Symptom Checklist-90-R (SCL-90-R) Towers Test of Delis-Kaplan Executive Function System (D-KEFS) Weschler Abbreviated Scale of Intelligence (WASI) Weschler Adult Intelligence Scale (WAIS-III) Weschler Intelligence Scale for Children IV (WISC-IV)

Name of Client: Date of Birth: Date of Evaluation: 8 Risk and Amenability Instruments Structured Assessment of Violence in Youth (SAVRY) Risk-Sophistication-Treatment Inventory (RSTI) Youth Level of Service / Case Management Inventory (YLS/CMI) Collateral Sources Consulted Parent / Guardian / Primary Caretaker Juvenile Justice Probation & Parole CYFD Protective Services Detention Behavioral History Police Reports Medical Records from: Hospital Records from: School Records from: Cognitive / Intelligence Testing Records from: Developmental Disabilities Assessment Records from: Disability Determination Records from: Neurological Examination Records from: Neuropsychological Assessment from: Substance Use Testing Records from: Substance Use Treatment Records from: Admission / Discharge Records from: Out-patient Assessment / Treatment Records from: Sexual Offender Evaluation from: Functional Assessment from: