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Lawrence V. Tucker, M.D.
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Forensic Client Form
Home
Forensic Client Form
Name of Client
*
Client's phone number
*
Client's e-mail address
Name of Attorney
*
Attorney's phone number
*
Attorney's e-mail address
*
Case Number
*
County of Case
*
Questions to be answered for client
Expected date of trial
*
Date the full report is needed?
*
Who will pay for the services?
*
Client will pay
Attorney will pay
Other
Type of Referral: {please check all apply}
*
DUI
FITNES FOR DUTY
CUSTODY EVALUATION
JURY SELECTION EVALUATION
PSYCHOPHARMACOLOGY
CLOSE HEAD INJURY/TRAUMATIC BRAIN INJURY
POST-TRAUMATIC STRESS DISORDER (PTSD)
ISSUES OF SUBSTANCE ABUSE/ADDICTION
EVALUATION ANGER AND HOSTILITY
EVALUATION POST MOTOR VEHICLE BEHAVIORAL HEALTH INJURIES
EVALUATE FOR NEUROPSYCHOLOGICAL SEQUELAE FROM HEAD INJURIES
MALPRACTICE FOR PSYCHIATRIC TREATMENT
WRONGFUL DEATH FROM PSCHIATIATRIC TREATMENT
WRONGFUL DEATH FROM SUICIDE
PERMANENT DAMAGES FROM PSYCHOTROPIC DRUG REACTION
INCORRECT DIAGNOSIS LEADING TO LOSS OF JOB
DISCRIMINATION FROM EMPLOYMENT DUE TO MENTAL ILLNESS
IMPROPER DIAGNOSIS LEADING AND TREATMENT LEADING TO ARREST FOR SUBSTANCE ABUSE
NURSING HOME IMPROPER TREATMETN OF BEHAVIOR OF DEMENTIA AND ALZHEMIERS DIEASE
DANGEROUSNESS RISK ASSESSMENT AND PERSONAL INJURY INCLUDING ASSESSMENT OF EMOTIONAL TRAUMA
ISSUES INVOLVING INPATIENT PSYCHIATRIC CARE, INPATIENT PSYCHIATRIC POLICIES & PROCEDURES
Please provide any further explanation needed pertaining to case
Please attach all necessary documents
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