Psychological Medico-Legal Report Form
Complete this form to provide the information needed to prepare a psychological medico-legal report.
Requester and Case Details
Requester Full Name
*
First Name
Middle Name
Last Name
Professional Role or Organization
*
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Case/Reference ID
*
Preferred Report Delivery Method
*
Please Select
Email
Secure Portal
Postal Mail
In Person
Other
Examinee and Evaluation Context
Examinee Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Evaluation Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Evaluation Context
*
In-person
Telehealth
Records review only
Other medico-legal context
Medico-Legal Referral Information
Referral source
*
Legal or case background summary
*
Referral question
*
Date of incident or relevant event
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current psychological concerns
Brief relevant history summary
Clinical Observation and Report Output
Observed presentation during interview
*
Functional impact summary
*
Report purpose / opinion focus
*
Please Select
Clinical summary
Capacity/functional opinion
Causation opinion
Risk-related opinion
Fitness for duty
Other
Special instructions for the report
Submit Report Request
Should be Empty: