13-14455-360 Revised March 5, 2020
Superior Court of California
County of San Bernardino
247 West 3
rd
Street, 11
th
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:
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