1 IN THE CIRCUIT COURT OF COUNTY, ARKANSAS DIVISION STATE OF ARKANSAS VS CASE NO. : (FULL NAME OF DEFENDANT) Date of Birth Sex Race OFFENSE(S) CHARGED AND CODE NOS.: PROSECUTING ATTORNEY222S NAME AND ADDRESS: DEFENSE ATTORNEY222S NAME AND ADDRESS: NAME OF ATTORNEY REQUESTING EXAMINATION: ARKANSAS ARREST TRACKING NUMBER: DEFENDANT222S CUSTODY STATUS AND LOCATION: ORDER FOR CRIMINAL RESPONSIBILITY EXAMINATION OF DEFENDANT Pursuant to Ark. Code Ann. 247 5-2-301 et seq., the defendant has filed notice that he/she intends to rely on the defense of lack of criminal responsibility and American LegalNet, Inc. www.FormsWorkFlow.com 2 has petitioned the Court for a criminal-responsibility examination and opinion. It is therefore ORDERED: 1. All further proceedings in the prosecution are immediately suspended. 2. The defendant shall undergo examination by one (1) or more disinterested qualified psychiatrists or qualified psychologists: (name, address, and telephone no. of the examiner): 3. The prosecuting attorney shall provide a copy of this Order to the examiner. 4. The prosecuting attorney shall provide the examiner any information relevant to the examination, including but not limited to: A. The name and address of any attorney involved in the matter; B. Information about the alleged offense(s); and C. Any information about the defendant222s background that is determined to be relevant to the examination, including the criminal history of the defendant. 5. Pursuant to Ark. Code Ann. 247 5-2-328(b)(4), the Court directs the attorney for the defendant to provide the following information to the examiner: (If required, check all boxes that apply.) Psychiatric records; Medical records; Records pertaining to treatment of the defendant for substance or alcohol abuse; and/or Additional information as identified below: American LegalNet, Inc. www.FormsWorkFlow.com 3 6. The examiner shall provide a report to this Court that includes the following: A. A description of the nature of the examination; B. An opinion as to whether as the result of a mental disease or defect the defendant at the time of the alleged offense lacked the capacity to appreciate the criminality of his or her conduct or to conform his or her conduct to the requirements of law, an explanation of the examiner222s opinion, and the basis of the opinion; and C. (check if required) When directed by the Court, an opinion as to whether at the time of the alleged offense the defendant lacked the capacity to form a culpable mental state that is required to establish an element of the alleged offense with an explanation of the examiner222s opinion and the basis of the opinion. 7. If at any point during the criminal-responsibility examination the examiner believes that the defendant is not fit to proceed, the examiner shall not render an opinion or issue a report on the defendant222s lack of criminal responsibility until this Court makes a determination as to the defendant222s fitness to proceed. 8. If an examination cannot be conducted because of the unwillingness of the defendant to participate in the examination, the report shall so state and shall include an opinion as to whether the unwillingness of the defendant is the result of mental disease or defect. 9. The examination shall be for a period not exceeding sixty (60) days or if applicable such longer period as the Director of the Division of Aging, Adult, and Behavioral American LegalNet, Inc. www.FormsWorkFlow.com 4 Health Services [DAABHS] or his or her designee determines to be necessary for the purpose of the examination. 10. The examiner shall file the report of the examination with the Clerk of the Court and shall provide a copy of the report to DAABHS. 11. The Clerk of the Court shall provide a copy of the report to the defense attorney and the prosecuting attorney. IT IS SO ORDERED. Date Circuit Judge American LegalNet, Inc. www.FormsWorkFlow.com