Court-Ordered Psychological Assessment Questionnaire
Please complete this questionnaire to assist with your court-ordered psychological assessment. Answer each question as accurately as possible.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Current Living Situation
*
With family
Alone
With others (not family)
Other
Reason for Court-Ordered Assessment
*
Please Select
Child custody evaluation
Competency evaluation
Risk assessment
Other legal matter
Other
Please rate the level of stress you have experienced in the past month.
*
1
2
3
4
5
Please indicate how much you agree with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I have difficulty managing my emotions.
1
2
3
4
5
I feel supported by people around me.
6
7
8
9
10
I have a history of legal issues.
11
12
13
14
15
I am able to cope with daily stressors.
16
17
18
19
20
Briefly describe any current concerns or symptoms you wish to share.
I confirm that the information provided in this form is accurate to the best of my knowledge and is submitted for the purposes of the Court-Ordered Psychological Assessment Questionnaire.
*
I acknowledge and confirm
Submit
Should be Empty: