Table 1

Competence to Stand Trial Report: Sample Format

  1. Identifying information

  2. Source of referral, reason for referral, and statement of the charges

  3. Relevant legal standards and criteria

  4. Informed consent/statement of nonconfidentiality

  5. Dates and durations of examinations

  6. Sources of information: third-party information including records reviewed, collaterals sources interviewed

  7. Relevant background information

    1. )Family history

    2. ) Personal history

    3. )Education history

    4. )Employment history

    5. )Religious history

    6. )Military history

    7. )Sexual, marital, and relationship history

    8. )Medical history

    9. )Drug and alcohol history

    10. )Legal history (juvenile and adult crimes and civil matters)

    11. )Psychiatric history

  8. Relevant physical examination, imaging studies, and laboratory tests

  9. Psychological testing and assessment instruments administered; dates completed as well as any repeated testing, including notation regard-ing any nonstandard instruction or administration

  10. Current mental status examination (during the evaluation)

  11. Competency examination data

  12. Clinical conclusions and diagnoses that are relevant to competency

  13. Medicolegal conclusions including expert opinion competency if formulated

  14. Opinion on restorability and commitability, if formulated

  15. Formulation and basis for the expert opinion(s)