Davidson County Mental Health Court Referral Form Please allow 4 business days for us to complete your new candidate form. "*" indicates required fields Appearance InformationReferral Date* MM slash DD slash YYYY Next Court Date* MM slash DD slash YYYY Referral InformationTitle/Organization*Referrer Name* First Last PhoneExtensionEmail Referral ReasonAttorney InformationAttorney Name* First Last Attorney PhoneExtensionAttorney Email* HAVE YOU REVIEWED WITH THE CLIENT THAT MENTAL HEALTH COURT IS A VOLUNTARY PROGRAM?* Yes No HAS THE CLIENT CONSENTED TO THE REFERRAL?* Yes No Client InformationClient Name* First Middle Last Suffix OCAAgeGenderPlease Select.....MaleFemaleRacePlease Select...American Indian or Alaskan IndianAsianAsian or Pacific IslanderBlackHispanicNative American or Alaska NativeNative Hawaiian or Other Pacific IslanderWhiteOtherUnknownMarital StatusPlease Select.....SingleMarriedDivorcedSeparatedWIdowedClient Home Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Client PhoneMental Health InformationHas the client given consent to share this information with the Mental Health Court Staff?* Yes No Has the client participated in MHC before? Yes No Has the client had a prior Mental Health diagnosis? Yes No Diagnosis according to client:Where has the client received this diagnosis and/or treatment?Case InformationCourt TypePlease Select.....General SessionsCriminal CourtWarrant Number(s)Current Charge(s)DispositionDrug of choiceCurrently on probation? Yes No Current P.O.Pending Cases Outside of Davidson County? Yes No Holds? Yes No Is client in custody? Yes No Case DetailsIs this is an open, unajudicated case or a probation violation from criminal court?*If any of the above is true, please select "Yes". Yes No Does the defendant have a history of charges for sex offenses, arson, murder or attempted murder?* Yes No CaptchaNameThis field is for validation purposes and should be left unchanged.
