Psychosexual Evaluation Referral - Bevill and Associates Behavioral Health

Psychosexual Evaluation Referral Form (optional)

The Forensic Evaluation Program at Bevill and Associates LLC located in Birmingham, AL offers a range of assessment and treatment to address the needs of individuals with sexual behavioral problems including sexual offenses and sexual victimization.

Client Name - First / Last

Date of Birth

Sex

Male

Female

Primary Spoken Language

Email (optional)

Phone Number (optional)

Address

City

State

Description of Charges or Allegations

Court Jurisdiction:

State (Criminal)

Federal (Criminal)

Family Court - Custody Cases

Licensing Board / Employment

Legal Status:

Pre Adjudicated (criminal)

Adjudicated - Pre Sentencing (criminal)

Pre Hearing (Custody / Family Court)

Complaint (Licensing Board / Employer)

Any Current Restrictions

Referral Request - Type of Evaluation

Psychosexual Evaluation (Criminal in Scope)

Psychosexual Evaluation (Child Custody in Scope)

Psychosexual Evaluation (Professional Licensing Board or Employer)

Attorney / Licensing Board / Referral Source Information

First and Last Name

Name of Law Firm / Board/ Employer/ Court:

Address

City

State

Zip Code

Phone Number

Email Address

Financial - Responsible Party

The fee for this evaluation is $1,500, one half ($750) of the evaluation fee prior to the start of the evaluation, unless a third party such as the court has agreed to pay for the evaluation. If the evaluation or any part of the evaluation is preformed outside the office of Bevill and Associates LLC, the responsible party is responsible for the milage expense at a rate of $.55 per mile. All fees must be paid in secured funds (certified check, money order or credit card) a 3.75% processing fee will be applied to all credit card charges. If a third party is paying for the evaluation, then this third party must sign a financial agreement before the evaluation begins. Expert testimony in court, conferences with attorneys, court officials, licensing boards, and telephone consultation about the report will be charged at $200 per hour. If you plan to call your therapist or evaluator as an expert witness in your case, then you will need to pay a retainer fee in advance, which will cover 5 hours of services. This would be $1,000 for 5 hours and additional hours will be billed at $200 per hour.

Electronic Signature

By typing your full name indicates that you have read and understand the above-stated conditions.

I agree that my typed name below will be as valid as a handwritten signature to the extent allowed by local law

Release of Mental Health Protected Information to referral source (optional)

This form is used for Bevill and Associates to release any information and/or assessment results to attorneys, Boards, the court system or any other agency on behalf of the client.

https://bevillandassociates.com/wp-content/uploads

Release of completed and signed Release of Mental Health Information Upload (optional)

Choose file

Uploading… (0%)

A file with this name has already been uploaded.

This file type isn’t allowed.

This file size is too big.

Discovery, Court Decree, Case Documents (optional)

Choose file

Uploading… (0%)

A file with this name has already been uploaded.

This file type isn’t allowed.

This file size is too big.

I agree to the terms and conditions