Tài liệu The Forensic DOCUMENTATION SOURCEBOOK ppt

The Forensic
DOCUMENTATION
SOURCEBOOK
The Complete Paperwork Resource for
Forensic Mental Health Practice

SECOND EDITION
Theodore H. Blau
Fred L. Alberts, Jr.

John Wiley & Sons, Inc.




The Forensic
DOCUMENTATION
SOURCEBOOK





The Forensic
DOCUMENTATION
SOURCEBOOK
The Complete Paperwork Resource for
Forensic Mental Health Practice

SECOND EDITION

Theodore H. Blau
Fred L. Alberts, Jr.

John Wiley & Sons, Inc.


This book is printed on acid-free paper.
Copyright © 2004 by John Wiley & Sons, Inc. All rights reserved.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.
Published simultaneously in Canada.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means,
electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108
of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization
through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive,
Danvers, MA 01923, (978) 750-8400, fax (978) 646-8600, or on the web at www.copyright.com. Requests to the
Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River
Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 748-6008.
Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this
book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this
book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No
warranty may be created or extended by sales representatives or written sales materials. The advice and strategies
contained herein may not be suitable for your situation. You should consult with a professional where appropriate.
Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, including but
not limited to special, incidental, consequential, or other damages.
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It
is sold with the understanding that the publisher is not engaged in rendering professional services. If legal, accounting,
medical, psychological or any other expert assistance is required, the services of a competent professional person
should be sought.
Designations used by companies to distinguish their products are often claimed as trademarks. In all instances where
John Wiley & Sons, Inc. is aware of a claim, the product names appear in initial capital or all capital letters. Readers,

however, should contact the appropriate companies for more complete information regarding trademarks and
registration.
For general information on our other products and services please contact our Customer Care Department within the
United States at (800) 762-2974, outside the United States at (317) 572-3993 or fax (317) 572-4002.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be
available in electronic books. For more information about Wiley products, visit our web site at www.wiley.com.
Note about Photocopy Rights
The publisher grants purchasers permission to reproduce handouts from this book for professional use with their
clients.
ISBN 0-471-68288-8
Printed in the United States of America.
10 9 8 7 6 5 4 3 2 1


To Dr. Theodore H. Blau (1928–2003) whose intellect, generosity, and gracious presence is greatly missed.





Contents
CD Contents xv
Acknowledgments xix
Introduction xxi
Chapter 1 Initiating Forms 1.1
Form 1 Forensic Intake
Sample Form 1.6
Example of Completed Form 1.7
Form 2 Charge Sheet
Sample Form 1.8

Example of Completed Form 1.9
Form 3 Terms of Agreement Letter
Sample Form 1.10
Form 4 Terms of Engagement Contract
Sample Form 1.11
Form 5 Case Chronology
Sample Form 1.13
Example of Completed Form 1.14
Form 6 Case Material Received
Sample Form 1.15
Example of Completed Form 1.16
Form 7 Case Materials Sent
Sample Form 1.17
Example of Completed Form 1.18
Form 8 Forensic Intake Sheet (Pre-Examination)
Sample Form 1.19
Example of Completed Form 1.20
Form 9 Preselection Interview Form
Sample Form 1.21
vii
Contents
Chapter 2 Initiating the Assessment Process 2.1
Form 10 Background Summary—From Record Review
Sample Form 2.4
Example of Completed Form 2.5
Chapter 3 Initiating a Forensic Evaluation 3.1
Form 11 Apprisal of Rights
Sample Form 3.5
Example of Completed Form 3.6
Sample of Spanish Language Form (Aviso de Derechos) 3.7

Form 12 Authorization for Release of Psychological Information
Sample Form 3.8
Example of Completed Form 3.9
Form 13 Authorization for Release or Receipt of Information
Sample Form 3.10
Form 14 Psychological Evaluation Informed Consent
Sample Form 3.11
Chapter 4 Process Forms 4.1
Form 15 Informed Consent—Child Custody/Visitation Evaluation
Sample Form 4.22
Example of Completed Form 4.23
Form 16 Informed Consent—Custody and Visitation Evaluation
Sample Form 4.24
Example of Completed Form 4.25
Form 17 Informed Consent—Release of Records
Sample Form 4.26
Form 18 Informed Consent
Sample Form 4.27
Form 19 Authorization for Release of Psychological Information
Sample Form 4.28
Form 20 HIPAA Compliant Protected Health Information Disclosure
Authorization
Sample Form 4.29
Form 21 Permission to Release Confidential Records
Sample Form 4.30
Form 22 Family History—Child
Sample Form 4.31
Example of Completed Form 4.34
Form 23 Adult History
Sample Form 4.37

Example of Completed Form 4.39
viii
Contents
Form 24 Test Room Schedule
Sample Form 4.41
Example of Completed Form 4.43
Form 25 Family Conference
Sample Form 4.45
Example of Completed Form 4.46
Form 26 Neuropsychological Symptom/Sign/Course
Sample Form 4.47
Example of Completed Form 4.48
Form 27 Posttraumatic Stress Disorder
Sample Form 4.49
Form 28 Drug Use History
Sample Form 4.52
Example of Completed Form 4.53
Form 29 Medications
Sample Form 4.54
Form 30 Clinical Observations
Sample Form 4.55
Example of Completed Form 4.56
Form 31 Assessment Time Log
Sample Form 4.57
Example of Completed Form 4.58
Form 32 Behavioral Symptomatology of Borderline Personality
Sample Form 4.59
Form 33 Glasgow Coma Scale and Trauma Score
Sample Form 4.60
Form 34 Items Frequently Used to Assess Mental Status in

Dementing Patients
Sample Form 4.61
Form 35 Competency Evaluation Instrument
Sample Form 4.62
Form 36 Insanity Defense Evaluation
Sample Form 4.63
Form 37 Reporting Sanity and Competence Findings
Sample Form 4.64
Form 38 Institutional Cost Survey
Sample Form 4.65
Example of Completed Form 4.66
Form 39 Clinical Procedures Note
Sample Form 4.67
Form 40 Limits of Confidentiality
Sample Form 4.68
Form 41 Follow-Up Contacts
Sample Form 4.69
ix
Contents
Form 42 Wechsler Scales—Comparison Sheet
Sample Form 4.70
Example of Completed Form 4.71
Form 43 Wechsler Scales for Children—Comparison Sheet
Sample Form 4.72
Example of Completed Form 4.73
Form 44 Achievement Tests Comparison Sheet
Sample Form 4.74
Example of Completed Form 4.75
Form 45 Testing Comparison Sheet—Wechsler Scales
Sample Form 4.76

Form 46 Psychological Autopsy Face Sheet
Sample Form 4.77
Example of Completed Form 4.78
Form 47 Evaluation of Pre-Terminal Month—Psychological Autopsy
Sample Form 4.79
Example of Completed Form 4.80
Form 48 Psychological Autopsy Interview
Sample Form 4.81
Form 49 Final Form for Psychological Autopsy
Sample Form 4.82
Example of Completed Form 4.83
Form 50 Visitation Questionnaire
Sample Form 4.84
Example of Completed Form 4.85
Form 51 The Best Interests of the Child—Parent Evaluation
Worksheet
Sample Form 4.86
Example of Completed Form 4.87
Form 52 The Best Interests of the Child—Workup Sheet
Sample Form 4.88
Example of Completed Form 4.89
Form 53 The Best Interests of the Child
Sample Form 4.90
Example of Completed Form 4.91
Form 54 Meeting the Best Interests of the Children: Parental
Summary
Sample Form 4.92
Example of Completed Form 4.93
Form 55 Visitation Plan Outline
Sample Form 4.94

Form 56 Standard Paragraphs for Custody or Visitation Plan
Sample Form 4.95
Form 57 Wisconsin Card Sort
Sample Form 4.96
Example of Completed Form 4.97
x
Contents
Form 58 Trials A and B
Sample Form 4.98
Example of Completed Form 4.99
Form 59 Hand Dynamometer
Sample Form 4.100
Example of Completed Form 4.101
Form 60 Formulae and Worksheet for Estimating Premorbid
WAIS-R Scores
Sample Formulae Form 4.102
Sample Worksheet Form 4.103
Form 61 MMPI-2 Comparison
Sample Form 4.104
Form 62 Probability of Malingering Checklist
Sample Form 4.105
Form 63 Factors That Increase Potential Incredibility and Distortion
in the Testimony of Children
Sample Form 4.106
Form 64 Scoring Sheet for Detecting Malingering on the Booklet
Category Test
Sample Form 4.107
Example of Completed Form 4.108
Form 65 Scoring Sheet for Detection of Malingering on the Luria-
Nebraska Neuropsychological Battery

Sample Form 4.109
Example of Completed Form 4.110
Form 66 Scoring Sheet for the Identification of Malingered Head
Injury on the Wechsler Adult Intelligence Scale—Revised
Sample Form 4.111
Example of Completed Form 4.112
Form 67 A Malingering Index for the Wechsler Memory
Scale—Revised
Sample Form 4.113
Example of Completed Form 4.114
Form 68 Lees-Haley Fake Bad Scale (FBS) for the MMPI-2
Sample Form 4.115
Example of Completed Form 4.116
Form 69 Invalidity/Fake Bad/Exaggeration/Malingering Profile
Sample Form 4.117
Example of Completed Form 4.118
Chapter 5 Forms for Deposition and Trial Preparation 5.1
Form 70 Depositions and Court Appearances
Sample Form 5.5
Example of Completed Form 5.6
xi
Contents
Form 71 Distribution of Forensic Cases
Sample Form 5.7
Example of Completed Form 5.8
Form 72 Time Distribution
Sample Form 5.9
Example of Completed Form 5.10
Form 73 Deposition and Conference Record
Sample Form 5.11

Example of Completed Form 5.12
Form 74 Rules of the Road for the Expert Witness at Trial
Sample Form 5.13
Form 75 Day in Court Checklist
Sample Form 5.14
Chapter 6 Forms for Family Law Consultation 6.1
Form 76 Parental Concordance about Child’s Adaptation
Sample Form 6.6
Example of Completed Form 6.7
Form 77 Evaluation of Credibility Assessment
Sample Form 6.8
Example of Completed Form 6.9
Form 78 Parental Like/Don’t Like Identifications
Sample Form 6.10
Example of Completed Form 6.13
Form 79 Parental Like/Don’t Like Identifications
Sample Form 6.16
Example of Completed Form 6.20
Form 80 Discipline Style Checklist
Sample Form 6.24
Example of Completed Form by Father 6.26
Example of Completed Form by Mother 6.28
Form 81 How Do Your Parents Discipline You?
Sample Form 6.30
Example of Completed Form 6.31
Form 82 Collateral Interview
Sample Form 6.32
Example of Completed Form 6.33
Form 83 General Recommendations
Sample Form 6.34

Chapter 7 Forms for Neuropsychological Assessment 7.1
Form 84 The Rancho Scale
Sample Form 7.8
xii
Contents
Form 85 Malingering of Head Trauma Symptoms on Halstead-
Reitan Subtests
Sample Form 7.9
Form 86 Detecting “Fake Bad” of Cognitive Impairment
on the Category Test
Sample Form 7.10
Form 87 Malingering and the WAIS-III
Sample Form 7.11
Example of Completed Form 7.12
Form 88 Infrequency—Psychopathology Scale
Sample Form 7.13
Form 89 Identification of “Faking Good” and “Faking Bad”
(F-K Normative Data)
Sample Form 7.14
Form 90 Symptoms Claimed/Observed
Sample Form 7.15
Example of Completed Form 7.16
Form 91 Detection of Malingering of Personality Pathology
on the Psychopathic Personality Inventory
Sample Form 7.17
Form 92 Frontal Lobe Personality Scale
Sample Form 7.18
Form 93 Summary of Brain-Behavior Deficits Found through
Neuropsychological Evaluation
Sample Form 7.19

Example of Completed Form 7.20
Chapter 8 Miscellaneous Forms 8.1
Form 94 Notice That Test Materials Require Qualified Reviewer
Sample Form 8.8
Form 95 Cover Letter—Raw Data Not Released
Sample Form 8.9
Form 96 Request for Records by Nonpsychologists
(Forensic)—Ethical Guidelines
Sample Form 8.10
Form 97 Attorney’s Presence during Psychological Examination
Sample Form 8.11
Form 98 Videotaping during Testing
Sample Form 8.12
Form 99 Memorandum of Understanding
Sample Form 8.13
Example of Completed Form 8.14
Form 100 Cast Study Enquiry
Sample Form 8.15
Example of Completed Form 8.16
xiii
Contents
Form 101 End of Contact
Sample Form 8.17
Example of Completed Form 8.18
Form 102 Useful Records to Be Obtained for the Expert Witness
Sample Form 8.19
Example of Completed Form 8.20
Form 103 Trial Consultation Plan
Sample Form 8.21
Example of Completed Form 8.22

Form 104 Expert Testimony Test Instrument Data
Sample Form 8.23
Example of Completed Form Used in Custody Test Battery 8.24
Example of Completed Form Used in Fitness to Drive Test Battery 8.25
CD Information C.1

xiv

CD Contents
1. Forensic Intake 1.6
2. Charge Sheet 1.8
3. Terms of Agreement Letter 1.10
4. Terms of Engagement Contract 1.11
5. Case Chronology 1.13
6. Case Material Received 1.15
7. Case Materials Sent 1.17
8. Forensic Intake Sheet (Pre-Examination) 1.19
9. Preselection Interview Form 1.21
10. Background Summary—From Record Review 2.4
11. Apprisal of Rights 3.5
11b. Aviso de Derechos 3.7
12. Authorization for Release of Psychological Information 3.8
13. Authorization for Release or Receipt of Information 3.10
14. Psychological Evaluation Informed Consent 3.11
15. Informed Consent—Child Custody/Visitation Evaluation 4.22
16. Informed Consent—Custody and Visitation Evaluation 4.24
17. Informed Consent—Release of Records 4.26
18. Informed Consent 4.27
19. Authorization for Release of Psychological Information 4.28
20. HIPAA Compliant Protected Health Information Disclosure Authorization 4.29

21. Permission to Release Confidential Records 4.30
22. Family History—Child 4.31
23. Adult History 4.37
24. Test Room Schedule 4.41
25. Family Conference 4.45
26. Neuropsychological Symptom/Sign/Course 4.47
27. Posttraumatic Stress Disorder 4.49
28. Drug Use History 4.52
29. Medications 4.54
xv
CD Contents
30. Clinical Observations 4.55
31. Assessment Time Log 4.57
32. Behavioral Symptomatology of Borderline Personality 4.59
33. Glasgow Coma Scale and Trauma Score 4.60
34. Items Frequently Used to Assess Mental Status in Dementing Patients 4.61
35. Competency Evaluation Instrument 4.62
36. Insanity Defense Evaluation 4.63
37. Reporting Sanity and Competence Findings 4.64
38. Institutional Cost Survey 4.65
39. Clinical Procedures Note 4.67
40. Limits of Confidentiality 4.68
41. Follow-Up Contacts 4.69
42. Wechsler Scales—Comparison Sheet 4.70
43. Wechsler Scales for Children—Comparison Sheet 4.72
44. Achievement Tests Comparison Sheet 4.74
45. Testing Comparison Sheet—Wechsler Scales 4.76
46. Psychological Autopsy Face Sheet 4.77
47. Evaluation of Pre-Terminal Month—Psychological Autopsy 4.79
48. Psychological Autopsy Interview 4.81

49. Final Form for Psychological Autopsy 4.82
50. Visitation Questionnaire 4.84
51. The Best Interests of the Child—Parent Evaluation Worksheet 4.86
52. The Best Interests of the Child—Workup Sheet 4.88
53. The Best Interests of the Child 4.90
54. Meeting the Best Interests of the Children: Parental Summary 4.92
55. Visitation Plan Outline 4.94
56. Standard Paragraphs for Custody or Visitation Plan 4.95
57. Wisconsin Card Sort 4.96
58. Trials A and B 4.98
59. Hand Dynamometer 4.100
60. Formulae and Worksheet for Estimating Premorbid WAIS-R Scores 4.102
61. MMPI-2 Comparison 4.104
62. Probability of Malingering Checklist 4.105
63. Factors That Increase Potential Incredibility and Distortion in the
Testimony of Children 4.106
64. Scoring Sheet for Detecting Malingering on the Booklet Category Test 4.107
65. Scoring Sheet for Detection of Malingering on the Luria-Nebraska
Neuropsychological Battery 4.109
66. Scoring Sheet for the Identification of Malingered Head Injury on the
Wechsler Adult Intelligence Scale—Revised 4.111
xvi
CD Contents
67. A Malingering Index for the Wechsler Memory Scale—Revised 4.113
68. Lees-Haley Fake Bad Scale (FBS) for the MMPI-2 4.115
69. Invalidity/Fake Bad/Exaggeration/Malingering Profile 4.117
70. Depositions and Court Appearances 5.5
71. Distribution of Forensic Cases 5.7
72. Time Distribution 5.9
73. Deposition and Conference Record 5.11

74. Rules of the Road for the Expert Witness at Trial 5.13
75. Day in Court Checklist 5.14
76. Parental Concordance about Child’s Adaptation 6.6
77. Evaluation of Credibility Assessment 6.8
78. Parental Like/Don’t Like Identifications 6.10
79. Parental Like/Don’t Like Identifications 6.16
80. Discipline Style Checklist 6.24
81. How Do Your Parents Discipline You? 6.30
82. Collateral Interview 6.32
83. General Recommendations 6.34
84. The Rancho Scale 7.8
85. Malingering of Head Trauma Symptoms on Halstead-Reitan Subtests 7.9
86. Detecting “Fake Bad” of Cognitive Impairment on the Category Test 7.10
87. Malingering and the WAIS-III 7.11
88. Infrequency—Psychopathology Scale 7.13
89. Identification of “Faking Good” and “Faking Bad” (F-K Normative Data) 7.14
90. Symptoms Claimed/Observed 7.15
91. Detection of Malingering of Personality Pathology on the Psychopathic
Personality Inventory 7.17
92. Frontal Lobe Personality Scale 7.18
93. Summary of Brain-Behavior Deficits Found through Neuropsychological Evaluation 7.19
94. Notice That Test Materials Require Qualified Reviewer 8.8
95. Cover Letter—Raw Data Not Released 8.9
96. Request for Records by Nonpsychologists (Forensic)—Ethical Guidelines 8.10
97. Attorney’s Presence during Psychological Examination 8.11
98. Videotaping during Testing 8.12
99. Memorandum of Understanding 8.13
100. Case Status Enquiry 8.15
101. End of Contact 8.17
102. Useful Records to Be Obtained for the Expert Witness 8.19

103. Trial Consultation Plan 8.21
104. Expert Testimony Test Instrument Data 8.23
xvii





Acknowledgments
The family of Theodore H. Blau is extremely grateful to Dr. Fred L. Alberts, Jr., for generously giving his
time and expertise to the revision of this text.
The family also recognizes and is extremely grateful to Dr. R. Bob Smith, III, for his initial help and
encouragement in pursuing this revision.
The text would not have been possible without them.
The Family of Theodore H. Blau





Introduction
All professional psychological work should be accurate and ethical. Errors of omission or commission are
likely to have serious repercussions in forensic psychological practice. In this setting, even small mistakes
can lead to embarrassment, criticism, licensing board sanctions, and possible criminal charges as well as
civil lawsuits. The devil is in the details.
The Forensic Documentation Sourcebook, 2nd ed. provides the structures likely to improve quality of
forensic psychological practice, enhance the reputation and credibility of the forensic psychologist, and
prevent improper or unfortunate occurrences.
Almost all of the forensic psychologist’s work is within the framework of adversary judicial activity.
Opposing counsels will search for errors or omissions that might suggest incompetence or questionable

credibility. The forensic psychologist should view this reality as a challenge and an opportunity to
demonstrate professional competence. The forms and procedural outlines herein were designed to help
accomplish this goal.
xxi



Chapter 1
Initiating Forms