Fillable COLLECTION OF INFORMATION FORM FOR MENTAL ILLNESS AND (Texas Real Estate Contracts)

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COLLECTION OF INFORMATION FORM FOR MENTAL ILLNESS AND (Texas Real Estate Contracts)

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The Texas Real Estate Commission (TREC) is an agency that governs real estate practices in the state of Texas USA. I its headquarters are located in Ausin Texas at 1700 North Congress.

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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)
SECTION I: DEFENDANT INFORMATION
Defendant Name (Last, First): Offense:
Date of Birth: CARE Identification # (If available): SID or CID # (If available):
Last Four Digits of Social Security Number:
Current County or Municipality of Incarceration: Date of Magistrate Order:
SECTION II: PREVIOUS HISTORY
Has the defendant been determined to have a mental illness or to be a person with an intellectual disability within the last
year?
☐Yes ☐No ☐ Unknown
Date of Previous Written Report of Collected Information (if applicable):
Previous Mental Health and/or Intellectual Disability Information (if available):
SECTION III: CURRENT INFORMATION
Most Recent Diagnosis(es) and Date(s) (if available):
At time of the collection of information or as indicated on the jail screening form for suicide and
medical/mental/developmental impairments, is the defendant acutely decompensated, suicidal, or homicidal according to
self-report?
☐Yes- Circle Above ☐No ☐ Not Applicable- Reason
Other relevant information pertaining to mental health and intellectual disability history and/or previous treatment or
service recommendations:
Observations and Findings Based on Information Collected:
☐Defendant is a person who has a mental illness. ☐Defendant is a person who has an intellectual disability.
☐There is clinical evidence to support the belief that the defendant may be incompetent to stand trial and should
undergo a complete competency examination under Subchapter B, Chapter 46B, Code of Criminal Procedure.
☐Any appropriate or recommended treatment or service:
☐None of the above.
Procedures Used to Gather Information:
SECTION IV: INFORMATION OF PROFESSIONAL SUBMITTING FORM
Name, Credentials & Organization of Person Submitting Form: Date of Submission:
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.
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)
INSTRUCTIONAL GUIDELINES
This form is not to be confused or supplemented by the “Screening Form for Suicide and Medical/Mental/Developmental
Impairments” as required by the Texas Commission on Jail Standards
Section I: DEFENDANT INFORMATION
Defendant Name should be filled out by last name followed by first name.
Offense information should include arresting offense information.
Date of Birth and last four digits of social security number are to be obtained to assist in validating identity.
CARE Identification # – If available, this number should be complimentary to the CCQ match.
SID or CID Number – If available, this number should include the State Identification Number (SID) or the
County Identification (CID) Number.
List the Current County or Municipality of the current incarceration.
Date of Magistrate Order should be the date the magistrate signed the order which initiates the timeframes
for completing the collection of information (not later than 96 hours for a defendant in custody; not later than
30 days for a defendant not in custody).
Section II: PREVIOUS HISTORY
Has the defendant been determined to have a mental illness or to be a person with an intellectual
disability within the last year?
If Yes
– The Magistrate
is not required
to order the interview and collection of other information if the
defendant
in the year proceeding
the defendant’s applicable date of arrest has been determined to
have a mental illness or to be a person with an intellectual disability by the service provider that
contracts with the jail to provide mental health or intellectual and developmental disability services,
local mental health authority, local intellectual and developmental disability authority, or another
mental health or intellectual disability expert described.
If No
– Further collection of information under this form will be necessary for applicable defendants.
If Unknown
- Further collection of information under this form may be necessary for applicable
defendants.
Previous Mental Health and/or Intellectual Disability Information and Date - If available, collect
information regarding whether the defendant has a mental illness as defined by Section 571.003, Health and
Safety Code, or is a person with an intellectual disability as defined by Section 591.003, Health and Safety Code,
including, if applicable, information obtained from any previous assessment of the defendant and information
regarding any previously recommended treatment.
Note: Include source of information. Examples are self-report, CARE or CCQ match, or clinical records
available from local mental health authority of local intellectual developmental disability authority.
Section III: CURRENT INFORMATION
Most Recent Diagnosis(es) and Date(s) - If available, include information here.
Is the client acutely (at time of written report of collected information or as indicated on the jail
screening form for suicide and medical/mental/developmental impairments) decompensated,
suicidal, or homicidal according to self-report?
If Yes
– select yes.
If No
– select no.
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.
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
Commission.
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.
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COLLECTION OF INFORMATION FORM FOR MENTAL ILLNESS AND (Texas Real Estate Contracts)

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Completed 6 May 2021

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