Forensic clinical services

FORENSIC CLINICAL SERVICES
PSYCHIATRIC SUMMARY
NAME: Donald Doe DATE: 12/24/09 CHART NO.: 001

IDENTIFYING INFORMATION:

Donald Doe is a 49-year-old African-American male who is charged with aggravated
battery to peace officer. He was examined at Forensic Clinical Services on December 24,
2009 in order to render an opinion regarding his fitness to stand trial and fitness to stand
trial with medications. The interview lasted one hour.
RECORDS REVIEWED:
1. Consolidated Referral Order dated November 24, 2009. 2. Chicago Police Department Arrest Report related to the alleged offense. 3. The defendant’s Criminal History Report. 4. Preliminary Assessment completed by Jane Smith, M.Ed., M.A. of Forensic Clinical Services dated December 16, 2009. 5. Medication Profile from Cermak Pharmacy dated December 18, 2009.
ARREST INCIDENT:

According to the available police reports, the defendant was identified as an individual who
was soliciting the sale of cannabis. When an attempt was made to arrest the defendant, he
allegedly swung his arms and struck a police officer numerous times.
ADVISORY OF NONCONFIDENTIALITY:
Prior to evaluating Mr. Doe, I informed him of the purpose and nonconfidential,
nontherapeutic nature of this assessment. He was further advised that the contents of our
discussion would be included in a report and sent to the court. Additionally, I informed
him that I may be required to testify in court as to the contents of my report. He
expressed an understanding of this advisory and agreed to participate in the examination.
CLINICAL INTERVIEW:
Mr. Doe presented to the evaluation as an African-American male of average height and
weight who appeared to be his stated age. His grooming and hygiene were good. He
stated that he is currently housed in on Division 2 (Cermak Health Services) of the Cook
County Jail for the past two months. He reported a significant history of depression and
stated that he continues to have some ongoing depressive symptoms. He denied any
suicidal ideations. He stated that his sleep has been improving with the medication. He
stated that he has been prescribed various medications including Effexor, Risperdal, and
FORENSIC CLINICAL SERVICES
PSYCHIATRIC SUMMARY
NAME Donald Doe DATE 12/24/09 CHART NO. 0901232
Doxepin. He stated that he is compliant with his medications. He denied any side effects
from the medications.
EVALUATION OF FITNESS:
Mr. Doe stated that he is being charged with aggravated battery to a police officer. He
identified this charge as a felony. He was able to distinguish a felony from a misdemeanor.
He stated that the role of his attorney was to “get me found not guilty.” He stated that the
role of the state’s attorney was to “get you found guilty.” He indicated that the judge
“listens to both sides. Decides if you are guilty or not guilty.” He was able to define both
verdicts. Additionally, he understood the consequences of each verdict. He was able to
spontaneously state his plea options of guilty and not guilty. Additionally, he understood
the consequences of each plea. He defined a plea bargain as “you plead guilty to a lesser
charge for a minimal amount of time.” He defined a jury trial as “twelve people that decide
your fate. Guilty or not guilty.” He defined a bench trial as “when the judge does the trial
without a jury.” He understood that he, as the defendant, had the right to choose whether
there would be a bench trial or a jury trial. He understood that he could not be compelled
to testify at his own trial. He defined evidence as “materials that help or hurt you from the
crime. Like a gun or a knife.” He defined witness as “somebody who has seen what
happened.” He stated that a witness would come to court a provide testimony as to what
they had observed. He understood that a witness would be required to take an Oath to tell
the truth prior to testifying. He stated that lying in court was called “perjury.” He indicated
that the judge could punish (“lock them up”) an individual who provided false testimony in
court. He denied having any difficulties communicating or interacting with his attorney.
He denied any side effects from his current medications.
PAST PSYCHIATRIC HISTORY:
Mr. Doe stated that he began exhibiting depressive symptoms in 2005 after the deaths of
various close family members. He stated that he was hospitalized at the Madden Mental
Health Center on at least two occasions. He reported depressive symptoms, anxiety, and
suicidal ideations. He stated that, as the depression worsened, he also exhibited mood-
congruent auditory hallucinations which would make derogatory statements towards him.
He stated that he was treated with Celexa and Vistaril. He received outpatient psychiatric
treatment through the Loretto Clinic under the care of a psychiatrist (Dr. Doshi) and
counselor (Ms. Bates). He stated that he would see his clinicians every couple of weeks.
He stated that he received psychiatric services while incarcerated in the Illinois Department
of Corrections (Vienna Correctional Center). He again reported symptoms of depression,
agitation, and anxiety. He was last hospitalized at the Madden Mental Health Center in
FORENSIC CLINICAL SERVICES
PSYCHIATRIC SUMMARY
NAME Donald Doe DATE 12/24/09 CHART NO. 0901232
October of 2009 for depression, anxiety, and suicidal ideations. He was prescribed
Risperdal and Remeron.
After his current arrest, he was admitted to Cermak Health Services of Cook County Jail
and treated for depression. A current medication profile from Cermak Pharmacy indicates
that he is prescribed Risperdal (antipsychotic/mood stabilizer) 4 mg per day, Effexor (an
antidepressant) 150 mg per day, and Doxepin (antidepressant often used as sleep aid) 200
mg at bedtime.

SUBSTANCE ABUSE HISTORY:

Mr. Doe began using alcohol at the age of thirteen. He stated that he began drinking daily
between the years of 1979 and 1989. He stated that he would generally drink
approximately twelve beers per day. He endorsed a history of blackouts but denied any
alcoholic withdrawal symptoms. Prior to his current arrest, he stated that he was drinking
only two times a week. He began using marijuana at the age of fourteen. He stated that he
used marijuana daily until the age of twenty. He denies any recent usage. He began using
cocaine at the age of fifteen. He stated that he only used it on a few occasions. He denied
any recent use of cocaine. He began using heroin at the age of fifteen. He stated that he
used heroin daily beginning in the mid 1980’s and this lasted for approximately fifteen
years. Prior to his current arrest, he stated that he was using heroin approximately one to
two times per month. He experimented with PCP and LSD prior to the age of twenty. He
denied any other history of illicit drug use.
PAST MEDICAL HISTORY:

Mr. Doe stated that he has suffered from seizures for the past several years. He stated that
he has not had a seizure in over one year. He stated that he was diagnosed with asthma in
1999. He stated that he is prescribed an inhaler for this. According to the defendant’s
medication profile from Cermak Pharmacy, he is prescribed medications for the treatment
of a seizure disorder (Dilantin) and asthma (Ventolin).
PAST LEGAL HISTORY:

Mr. Doe stated that he has been arrested on over 40 occasions. He stated that he has been
incarcerated in the Illinois Department of Corrections on 8 separate felony convictions. He
stated that his cases have all involved illegal drugs except for one charge where he was
convicted for writing a bad check (“deceptive practices”). He stated that his last conviction
occurred in 2007 for possession of a controlled substance. He stated that he pled guilty
(“copped out”) and was sentenced to three years. He served one year at the Vienna
FORENSIC CLINICAL SERVICES
PSYCHIATRIC SUMMARY
NAME Donald Doe DATE 12/24/09 CHART NO. 0901232
Correctional Facility and then was paroled in August of 2008. He stated that he violated
the terms of his parole and was re-incarcerated at the Galesburg Correctional Facility and
was released in February of 2009.
PSYCHOSOCIAL HISTORY:
Mr. Doe stated that he was born in Chicago and was the youngest in sibship of four. He
was raised by his mother and father. He denied any history of physical or sexual abuse.
He attended grammar school and high school in Chicago. He stated that he was enrolled in
regular classes and received average grades. He dropped out of Austin High School in the
tenth grade because he began working at a Department Store. He eventually obtained his
GED (2003) through a work release program located in the South Lawndale neighborhood.
He reported various jobs at various factories and at a Department Store. He stated that his
longest job (1981-1989) was at a company where he was employed filling orders for meat
products and loading/unloading trucks. He has never been married and has four children
(age range 14-34). He has never received Social Security Disability benefits. Prior to his
current arrest, he resided with his mother in Chicago.
MENTAL STATUS EXAMINATION:
Mr. Doe presented to the evaluation as an African-American male of average height weight
who appeared to be his stated age. His grooming and hygiene were good. His eye contact
was good. His speech was decreased in rate, rhythm, and volume. He described his mood
“depressed.” His affect was mildly blunted. His thought process was logical and goal
directed. His thought content revealed no current evidence of delusions, hallucinations,
suicidal ideation, or homicidal ideation.
On cognitive testing, he was alert and oriented to person, place, and time. He was able to
spell the word “world” forwards and backwards without difficulty. He was able to describe
the similarities of various word pairs that were presented to him. He gave appropriate
definitions when presented with various proverbs. His memory for recent and past events
was intact. He was able to recall 2 out of 3 words after five minutes. He was able to state
his next court date (December 30, 2009), and the name the of the president judge (Judge
Porter). He was able to name the past three presidents and relate current events in the
news.
DIAGNOSIS:
FORENSIC CLINICAL SERVICES
PSYCHIATRIC SUMMARY
NAME Donald Doe DATE 12/24/09 CHART NO. 0901232
Axis I Major Depressive Disorder, in partial remission

Axis II Deferred
Axis III History of seizure disorder
Asthma

FORENSIC FORMULATION AND OPINION:
Pursuant to Your Honor’s Order, the undersigned psychiatrist examined Donald Doe at
Forensic Clinical Services on December 24, 2009 in order to render an opinion regarding
his fitness to stand trial and fitness to stand trial with medications.
Based on the above examination and review of the available records, it is my opinion
within a reasonable degree of medical and psychiatric certainty that Donald Doe IS FIT
TO STAND TRIAL WITH MEDICATIONS. He is cognizant of the charge,
understands the nature and purpose of the legal proceedings, and shows the ability to
cooperate with counsel in his defense. He has a history of Depression which is currently
being treated with medications. He is prescribed Effexor (an antidepressant) 150 mg per
day, Risperdal (an antipsychotic/mood stabilizer) 4 mg per day, and Doxepin (an
antidepressant often used as a sleep aid) 200 mg at bedtime. He is not experiencing any
side effects from these medications which would impair his fitness.
Thank you for giving me the opportunity to examine this defendant. If you have any
questions or need clarification regarding this evaluation, please do not hesitate to contact
me.

Source: http://www.mentalcompetency.org/resources/forms/files/Cook%20Co%20--%20Psychiatric%20Summary%20--%20A.pdf