Davidson County Mental Health Court Referral Form Please allow 2 business days for us to review your application. "*" indicates required fields CompanyThis field is for validation purposes and should be left unchanged.Appearance InformationReferral Date* Next Court Date* Referral InformationTitle/Organization/Relationship to Person Being Referred*Referrer Name* First Last Phone*ExtensionEmail* Referral Reason (Needs of Client)*Attorney InformationAttorney Name* First Last Attorney Phone*ExtensionAttorney Email* Have you reviewed with the client that Mental Health Court is a voluntary program and has the client consented to the referral?* Yes No Have you reviewed with your client that Mental Health Court is an intensive form of supervision for a minimum of 18 months?* Yes No Client InformationClient Name* First Middle Last Suffix OCA*Age*Gender*Please Select.....MaleFemaleMTFFTMNONBINARYRace*Please Select...American Indian or Alaskan IndianAsianAsian or Pacific IslanderBlackHispanicNative American or Alaska NativeNative Hawaiian or Other Pacific IslanderWhiteOtherUnknownClient 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 Type of Housing* Group Home Sober Housing Unhoused With Family Independent Housing Other Can Client Return to this Address?* Yes No Client Phone*Mental Health InformationHas the client participated in Mental Health Court 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?*Is client currently seeing a mental health provider AND taking medications?* Yes No Case InformationCourt Type*Please Select.....General SessionsState Trial CourtOut of CountyCurrent Charge(s) and Warrant Number(s)*Proposed disposition from ADA*If there is a history of substance abuse, please list drug(s) of choiceCurrently on probation?* Yes No Location of Probation*Current P.O.*Pending Cases Outside of Davidson County?* Yes No Is client in custody?*If yes, please ensure that your client has put in a sick call to be seen for their mental health. Yes No Does client have any current holds?* Yes No Case DetailsHas the client ever been charged with any sex offense, any type of homicide, arson or stalking?* Yes No
