Davidson County Veterans Treatment Court Referral Form Please allow 2 business days for us to review your application. "*" indicates required fields FacebookThis field is for validation purposes and should be left unchanged.Appearance InformationReferral Date* Next Court Date* Referral InformationTitle/Organization*Referrer Name* First Last Phone*ExtensionEmail* Referral Reason*Attorney InformationAttorney Name* First Last Attorney Phone*ExtensionAttorney Email* Have your reviewed with the client that Veterans Treatment Court is a voluntary program?* Yes No Has the client consented to the referral?* Yes No Client InformationClient Name* First Middle Last Suffix OCA*Age*GenderPlease 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 Client Phone*Service InformationService Branch*Please Select...ArmyNavyAir ForceMarinesCoast GuardService Component*Please Select.....ActiveReserveNational GuardTime of ServiceYears*YearsMonthsMonthsWas Service Pre 9/11 or Post 9/11?* Pre 9/11 Post 9/11 During Discharge TypePlease Select.....HonorableAdministrative/Medical SeparationGeneral Under Honorable ConditionsOther than HonorableDishonorableAdditional Documents to be Attached/Included with this ApplicationPlease upload any additional documents such as DD 214, Enlisted/Officers Record Brief (Active Duty Defendants) as well as copies of warrants. If VOP include copy of warrant from original charge. Drop files here or Select files Max. file size: 1 GB. Mental Health InformationHas the client given consent to share this information with the Veterans Treatment Court Staff?* Yes No Has 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?*Case InformationCourt Type*Please Select.....General SessionsState Trial CourtOut of CountyCurrent Charge(s) and Warrant Number(s)*Disposition*If there is a history of substance abuse, please list drugs of choice.*Currently on probation?* Yes No Location of Probation*Current P.O.*Pending Cases Outside of Davidson County?* Yes No Case DetailsDoes Client have any Current Holds? Yes No Is client in custody? Yes No Has the client ever been charged with any sex offense, any type of homocide, arson or stalking?* Yes No
