By submitting this referral to Mental Health Court, you certify that the participant to be considered:
Referral made by:
Date of Referral*:
Name of participant referred*:
Date of Birth:
Current living situation*:
If Hospital, name the facility or if Jail, name the county:
Home address - street*:
City*: State*: Zipcode*:
Name of person who can always make contact with participant*:
Street or Postal Address*:
Describe the participants mental health history*:
Describe the participants medical history:
Participants current treatment provider:
For what type case do you wish the participant to be considered for mental health court?
New ChargeProbation ViolationParole Violation
If new offense, what is the new offense?
If probation or parole, what is the original offense that the participant is being supervised?
Has the defendant ever served in any branch of the United States Armed Forces?*
If yes, when and which branch?
Please convert to PDF and upload any warrants, arrest booking reports, law enforcement reports or criminal history data that may be available concerning the participant and this referral.