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Defendant

__________

(1) The undersigned is a qualified psychiatric examiner who, pursuant to the regulations adopted by the State Commissioner of Mental Health, is authorized to conduct an examination of the above-named defendant pursuant to and examination order issued by this court on [date] __ to determine whether the defendant has a dangerous mental disorder and, if the defendant does not have a dangerous mental disorder, to determine whether the defendant is mentally ill.

(3) On the basis of facts and information that the undersigned has obtained and on the basis of the observation and examination referred to in paragraph (2) of this report, it is the opinion and clinical judgment of the undersigned that:

□ (a) the above-named defendant has a dangerous mental disorder in that the defendant currently suffers from an affliction with a mental disease or mental condition which is manifested by a disorder or disturbance in behavior, feeling, thinking or judgment to such an extent that the defendant requires care, treatment and rehabilitation, and that because of such condition the defendant currently constitutes a physical danger to himself and others.

□ (b) the above-named defendant does not have a dangerous mental disorder, as that term is defined in paragraph (c) of subdivision 1 of CPL 330.20, but the above-named defendant is mentally ill in that the defendant currently suffers from a mental illness for which care and treatment as a patient, in the inpatient services of a psychiatric center under the jurisdiction of the State Office of Mental Health, is essential to such defendant's welfare and that his judgment is so impaired that he is unable to understand the need for such care and treatment.

□ (c) the above-named defendant does not have a dangerous mental disorder, as that term is defined in paragraph (c) of subdivision 1 of CPL 330.20, and the above-named defendant is not mentally ill, as that term is defined in paragraph (d) of subdivision 1 of CPL 330.20.

(4) Annexed hereto and made a part of this examination report is a detailed statement prepared by the undersigned which sets forth the following:

(a) the diagnosis and prognosis made by the undersigned concerning the defendant's mental condition;

(b) the findings and evaluation made by the undersigned concerning the defendant's mental condition;

(c) pertinent and significant factors in the defendant's medical and psychiatric history;

(d) the psychiatric signs and symptoms displayed by the defendant; and (e) the reasons for the opinion stated by the undersigned in paragraph (3) of this report [including, when defendant has a dangerous mental disorder, and explanation as to why, because of defendant's mental condition, he currently constitutes a physical danger to himself or others].

Dated: _________

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