COLLECTION OF INFORMATION FORM FOR
MENTAL ILLNESS AND INTELLECTUAL DISABILITY
AUTHORITY: Texas Code of Criminal Procedure art. 16.22; Texas Health and Safety Code § 614.0032
Approved by the Texas Correctional Office on Offenders with Medical or Mental Impairments (TCOOMMI)
If Not Applicable
– Indicate the reason why here.
Note: This information may be helpful to the magistrate or judge, as it will allow the magistrate or judge to
know the severity of the defendant’s mental health status for prioritization purposes.
Other relevant information pertaining to mental health history and/or previous treatment or service
recommendations – Note: Examples may include the following:
Previous competency examination results or outcome of examination results;
Parole, Probation or Pre-Trial Supervision status;
Military history is applicable to treatment history;
If this section is not applicable, indicate as such.
Observations and Findings Based on Information Collected– Select option as appropriate.
Note: Any appropriate or recommended treatment or service – Include whether the defendant warrants a
competency examination, outpatient services, etc. Provide any recommendation for further
assessment/evaluation by higher level clinical providers.
Procedures Used to Gather Information – Include informational sources used to collect information.
Examples may include: Sources of information such as, self-report, CARE or CCQ match, previous
psychological evaluations, assessments or clinical records available from local mental health authority of local
intellectual developmental disability authority. An interview to prepare the written report of collected information for the
purposes of this document may be gathered in the following ways: in person in the jail, by telephone, or through a telemedicine
medical service or telehealth service.
Section IV: INFORMATION OF PROFESSIONAL SUBMITTING FORM
Name, Credentials and Organization of Person Submitting Form – Person completing the form along
with his or her credentials, is to be listed here. Note: This form is to be completed by the local mental health authority,
local intellectual and developmental disability authority, or another qualified mental health or intellectual disability expert.
Date of Submission – Include the date the form is submitted to the Magistrate.
Note: Texas Code of Criminal Procedure art. 16.22(f) provides that this written report is confidential and not subject
to disclosure under Chapter 552, Government Code, but may be used or disclosed as provided by article 16.22.
Additionally, Texas Health and Safety Code section 614.017 requires the exchange of information relating to a special
needs offender or juvenile with a mental impairment between agencies to serve the purposes of continuity of care and
services regardless whether other state law makes that information confidential. The term “agency” includes but is not limited
to: A person with an agency relationship or contract with one of the following entities or individuals: Texas
Department of Criminal Justice; Texas Commission on Jail Standards; community supervision and corrections
departments and local juvenile probation departments; personal bond pretrial release offices established under Article
17.42, Code of Criminal Procedure; local jails regulated by the Texas Commission on Jail Standards; a municipal or
county health department; hospital district; judge of this state with jurisdiction over juvenile or criminal cases; an
attorney who is appointed or retained to represent a special needs offender, and/or the Health and Human Services
This form and the contents herein may only be shared in accordance with Texas Health and Safety Code § 614.017 and Texas Code of
Criminal Procedure article 16.22(f). This form and its contents are otherwise confidential and not subject to disclosure under
Chapter 552 of the Government Code.