Date of Evaluation:
DMHDD ID#: Date of Birth: Sex: Unit: Admit Date: Docket #
Current Legal Charge(s): Aggravated Battery to a Peace Officer, Resisting/Obstructing a Peace Officer, and Criminal Trespass to Real Property.
Mr. Doe is a 46 year old single African- American man from Winnebago County, IL. He was admitted to Elgin Mental Health Center (EMHC) after adjudication as Unfit to Stand Trial (UST) on 11/25/2003. (Evaluators name) evaluated Mr. Doe on date. Dr. Johnson found that Mr. Doe would have difficulty providing an adequate level of assistance to his lawyer in his own defense. The patient was considered to have an active psychosis which included paranoid delusions which could likely prevent him from being able to make informed court related decisions in his own self interest.
II. RESPONSE TO TREATMENT AND PRESENT LEVEL OF FUNCTIONING Hospital Course:
On admission Mr. Doe was considered oriented to person, date and place. He was not considered oriented to situation. He appeared agitated and restless. The patient reported being depressed although his presentation was more indicative of an elevated mood. Affect was labile and inappropriate to situation. Thought processes and content were disorganized. Speech was rambling, tangential, and loosely connected. A flight of ideas was present in his communication. The patient was experiencing auditory hallucinations and delusional thoughts with paranoid ideas. Insight and judgement were considered poor. Memory for short and long term recall was poor. Staff was unable to estimate level of intellectual functioning due to the level of current patient disorganization. Suicidal or homicidal ideas, plan or intent were denied and did not appear in evidence.
In treatment, Mr. Doe has been cooperative with recommended medication adjustments. His medication was changed several times due to his poor response. He has been on psychotropic medications such as Risperidone, Haloperidol 10 mg. a day, Haloperidol Decanoate 100 mg. injection once a month, Quetiapine 800 mg. a day, Ziprasidone 80 mg. a day and lately Olanzapine 20 mg. a day. He appears less agitated and restless overall. He takes extra medication periodically to control agitation. He becomes upset and frustrated when confronted with unit rules about minimum standards for behavior. Mr. Doe is restricted to the unit several times each month for minor rule infractions. His ability to comprehend and retain understanding of staff expectations appears impaired. The patient attends rehabilitative programming off unit with staff supervision.
The patient frequently approaches the nursing station with physical complaints and multiple requests. His ability to follow through with staff counseling suggestions is poor. He becomes argumentative and walks away mumbling to himself. He has not been violent or threatening to either patients or staff. He attends all recommended groups and activities. He is excluded from some groups because his rambling and tangential comments can be disruptive. He appears to have minimal to no insight regarding how his behavior is perceived by others.
Mr. Doe has been cooperative with discharge planning efforts. His previous counselor, has advised EMHC that the patient needs a higher level of community structure than named facility can give as an outpatient provider. Named facility has suggested EMHC contact another named facility and refer Mr. to their Adapt Program. Named facility has suggested that Mr. Doe would likely end up homeless if he were released to the community without some type of structured and supervised living program. The patient’s family has been contacted and they appear to agree with named facility’s view on this issue. No family member has indicated willingness to assist the patient if he were to be released from custody. Mr. Doe had a placement evaluation interview with, named facility on date. He is regarded as a good candidate for this program . When Mr. Doe November 15, 2004 is released from custody, the facility could provide housing, psychiatric follow up and other rehabilitative services. The treatment team at EMHC feels that facility could likely provide an appropriate level of care for Mr. Doe when he does return to the community.
Mental Status:
Mr. Doe is dressed in a blue sport shirt and black slacks. His shirt is tucked neatly in. His clothing appears in good repair. His hygiene and grooming appear fair. His speech volume is very low and difficult to hear. He is mumbling, apparently to himself. He may be responding to auditory hallucinations. His speech content is illogical, tangential and rambling. He is difficult to redirect back to the topic. He has several unrelated personal need requests he apparently wants to address with the interviewer. Mr. Doe is oriented to person, place and time. He is partially oriented to situation. When asked about his mood the patient replied he is “drowsy, excited, happy that God is with me”. He denies auditory hallucinations or delusional ideas. He denies any paranoid ideas. His affect is restricted. Judgement and insight appear poor. Contact with reality is marginal. Memory appears unimpaired. Intellectual functioning is estimated to be in the low average range. Mr. Doe denies any suicidal or homicidal ideas, plans or intent, and has exhibited no behaviors toward such ends.
III. Diagnoses
AXIS I: 295.30 Schizophrenia, Paranoid Type, 305.00 Alcohol Abuse,
305.20 Cannabis Abuse, 304.60 Cocaine Abuse AXIS: II: None
AXIS III: None
The following psychotropic medication are prescribed: 1. Olanzapine; an anti-psychotic, 10 mg: two times per day
2. Divalproex; a mood stabilizer used to augment the anti- psychotic, 1000mg, two times per day. IV. THE ISSUE OF FITNESS
Mr. Doe is attending this evaluation voluntarily and indicates he understands a court report will be written. Mr. Doe states that he is charged with: one out for you to talk for you to the judge.” It is evident he did not understand that this applied to the time of arrest incident rather than in court. I asked him also why he didn’t call the police when he felt threatened and he said, “ I don’t know why, even to this day.” “assaulting an officer and resisting
arrest”. He knew the name of his public defender and indicated he could reach his public defender by sending a letter to Winnebago County.
Mr. Doe reported the role of the judge in court is to “keep things on the level, he sentences, he listens”. He said the public defender “tries to help prove you’re not guilty”. The patient said the assistant state’s attorney “tries to go against you, say you did it, that you did the crime”. Mr Doe appears to have a partial understanding of basic court roles at a level similar to previous reports.
Mr. Doe reports that the term “guilty” means “you did it” and “not guilty” means “you didn’t do the charge”. He said a witness is “a person seen you do something”. Testimony is “talking about something, between the attorney and the judge, they call in the other attorney”. Cross-examine is the “state’s attorney and public defender talking, and the judge is there. The state’s attorney get’s his questions, the public defender gets to ask the judge, cross examines”. The patient defined evidence as “like a piece of paper or a watch”. When asked what the purpose of evidence was, Mr. Doe said to “let the police know, it was left at a crime”. The patient said a “bench trial” is “a trial of 12 peers, the judge asks the defendant things”. When asked what a “jury trial” is, Mr. Doe responded: “it’s the same, more freedom of movement around the activities, off grounds”. A verdict was defined as “a statement made by the jury”. He said a “plea bargain” is where “you plea guilty to a lessor charge”. The patient said this could result in “less time” or “they might let you go”. Mr. Doe appeared to know that a felony is more serious than a misdemeanor. He appeared to understand that a sentence is given by the judge.
Mr. Doe continues to have a limited understanding of court terms and basic court room procedures. Partially correct responses could not be elaborated upon in a coherent manner. Responses appeared superficial and vague. When asked follow up questions, the patient’s answers appeared to progressively deteriorate. His interview answers became rambling and tangential. Mr. Doe currently does not appear able to provide meaningful assistance to legal counsel in his own defense. He appears to have an inadequate understanding of basic court room terms and procedures. The clinical team believes the patient has made an earnest effort to attain fitness but is unable to do so. It is the clinical opinion of the treatment team at EMHC that Mr. Doe is Unlikely to Attain Fitness to Stand Trial within the mandated statutory time period with further treatment.
V. RESPONSIBLE STAFF
Summarized By: _______________________________________________ Social Worker II (Date)
_______________________________________________ MD, Psychiatrist (Date)
Section III.
This section covers different aspects of legal proceedings, and the treatment process for individuals found Not Guilty by Reason of Insanity. Included in this section are the following:
A. A flow chart for the legal proceedings for NGRI. The flow chart follows the procedure for NGRI finding.
B. The statute for Not Guilty by Reason of Insanity. C. Sample Orders:
1. Sample Court Order completed by the court finding an individual found Not Guilty by Reason of Insanity and in Need of Mental Health Services on an Inpatient Basis, and ordered to the State of Illinois Department of Human Services.
2. Sample Court Order completed by the court after a request has been filed by DHS requesting court approval for privileges.
3. Sample Court Order completed by the court after a request has been filed by DHS requesting Conditional Release.
D. An overview of the reports that are required in the NGRI Proceedings. E. Sample Cover Letters and Reports:
1. Sample Evaluation for Insanity completed by the expert evaluator assigned by the Court.
2. Template of 30 Day Report.
3. A copy of a Forensic Evaluation Report completed by the person supervising the inpatient treatment.
4. Sample cover letter to the court accompanying the Treatment Plan Report. 5. Template of 60 Day Report.
6. Sample Treatment Plan Report that summarizes the following: an assessment of the defendant’s treatment needs, a description of the services recommended for treatment, the goals of each type of element of service, an anticipated timetable for the accomplishment of the goals, and the designation of the qualified professional responsible for the implementation of the treatment plan. A Treatment Plan Report is required every 60-days.
F. A review of Facility Initiated Privileges with the following: 1. A cover letter for Privilege Request.
3. Sample Treatment Plan with recommendation for: Unsupervised On-Ground Pass Privileges, Supervised Off Grounds Pass Privileges.
4. Sample Report of a recommendation for Transfer to a Non-Secure Setting, Discharge or Conditional Release. Any recommendation for conditional release shall include an evaluation of the defendant’s need for psychotropic medications, what provisions should be made, if any, to ensure that the defendant will continue to receive psychotropic medications. following discharge, and what provisions will be made to assure the safety of the defendant and others in the event the defendant is no longer receiving psychotropic medications.
G. Recipient Initiated Privilege Request, the Henderson Information includes the following: general information, reference to relevant statute, specific instructions, commonly asked questions, cover letter to the Clerk, cover letter to the Judge, and petition for transfer, conditional release or discharge.
H. This subsection outlines the Community Agencies Responsibilities for patients who are conditionally release in a letter to the Local Provider, and provides; a template and a sample of both a letterhead and status report.
1. Letterhead template from the Community Agency 2. Sample of Cover letter from the Community Agency 3. Status Report template
4. Sample of Status Report
5. Template for Requests to the Courts Involving Recommendations on Conditional Release and Thiem (Discharge)