Page 100 - Juvenile Practice is not Child's Play

Has the client ever undergone a psychiatric or psychological evaluation? Yes No

For each evaluator:
Name:

Street address:

Phone:

Email, e-text, and website addresses:

Circumstances leading to evaluation:

Diagnosis or result of evaluation:

Does the client or his or her parent or guardian have paper or electronic documents that would contain

this contact information or information about the client’s treatment or performance?

Prior record (all arrests, from latest to earliest and any pending juvenile [and, if applicable, adult] charges, in any
jurisdiction):
Date of arrest:

Jurisdiction (city and state):

Charge(s):

Dismissal, diversion, or other resolution without trial or guilty plea: Plea (guilty or not guilty; if guilty, of what

charges):

Trial by judge or jury:

Name of judge:

Adjudication (guilty or not guilty; if guilty, of what charges):

Disposition:

Date disposition handed down:

Name of attorney:

Street address of attorney:

Phone number of attorney:

Email, e-text, and website addresses of attorney:
Time served:

Institution: