Request Evaluation Form – Arizona Forensics, LLC

Requesting Services For Your Client

Your name:*
Agency :
Address:
Office phone*
Alt. phone:
Fax:
Email :
Other:
Support staff :
Their phone:
Their email:
If your client is out – of – custody
please provide any contact information you might have .
Client name:*
Primary phone :*
Address:
Alt. phone:
FAX:
Email :
Other:
Who does our office send the bill to?
Client name:*
Agency :
Address:
Office phone:*
Alt. phone:
FAX:
Please provide a brief description of your client’s current situation, the instant event, etc.
Provide a brief description
What are some questions you would like address ed in the evaluation?
write questions you would like addressed
Are there specific tests or assessments you would like done?
- Psychosexual Evaluation
- State – of – Mind (“Mens Rea”)
- Full Psychological Evaluation
- ADD/ADHD assessment
- IQ assessment
- Autism assessment
- Memory assessment
- Other:
- Competency Evaluation (Rule 11)
Consultation / Research
If you are requesting consultation / research, please briefly describe the topics and questions you have.
briefly describe
Expert Testimony
If you are requesting expert testimony, please briefly describe the psychological matters in question.
briefly describe