Attachment_1_-_Agreement_for_Psychiatric_Appointments.pdf

13-14455-360 Revised March 5, 2020

Superior Court of California

County of San Bernardino 247 West 3rd Street, 11th Floor

San Bernardino, Ca. 92415-0302 doctorpanel@sb-court.org

Agreement to Accept Orders of Psychiatric/Psychological Appointment

Name: Email Address:

Address: Phone Number:

City/State/Zip: Fax Number:

CA. License Number:

I agree to accept Orders of Psychiatric/Psychological Appointment from the Superior

Court, County of San Bernardino to conduct the following types of evaluations (please select the evaluation types you are willing to conduct):

☐ PC1368/1369/1370 Competency Evaluation and Report

☐ PC1026/1027 NGI Evaluation and Report

☐ PC288.1 Sex Offender Evaluation and Report

☐ HS3050/3051 Narcotic Evaluation and Report

☐ EC1017 Defense-requested Evaluation and Report

☐ EC730 General Evaluation and Report

Please select the court district(s) where you are willing to accept appointments and provide testimony, if needed:

Please select to which of the following locations you are willing to travel:

☐ Arrowhead Regional Medical Center

☐ Central Detention Center

☐ Glen Helen Rehabilitation Center

☐ High Desert Detention Center (aka Adelanto)

☐ West Valley Detention Center

Please select the appointment type(s) you are willing to accept:

☐ Rush (10 days to submittal

☐ In custody

☐ Out of custody

Please list any foreign language abilities:

I understand that by accepting psychiatric/psychological appointments it is my responsibility to submit my report to the appointing court within twenty (20) days, along with my invoice, of my appointment unless other arrangements have been made by me with the appointing court.

I agree to accept appointments in accordance with the Court’s Appointed Service Fee Schedule rates currently in effect at the time of my appointment by the court. I further certify that the above information and the attached curriculum value are true and accurate.

Signature: Date:

PLEASE ATTACH YOUR CURRICULUM VITAE AND EMAIL TO doctorspanel@sb-court.org

☐ Joshua Tree

☐ Rancho Cucamonga

☐ San Bernardino

☐ Victorville mailto:doctorpanel@sb-court.org