Hendry County Treatment Courts Referral Form

Please review eligibility criteria prior to submission and complete all required information thoroughly to avoid any delays in processing. For referral questions please contact ehutchison@ca.cjis20.org

Referral Source Name

Referral Source Phone Number

Referral Source Agency

Judge

State Attorney's Office

Public Defender's Office

Office of Criminal Conflict and Civil Regional Counsel

Private Defense Attorney

Community Treatment Provider

Private Citizen or Family Member

Self-Referral

Other:

Defendant's Name

Defendant's Date of Birth

Defendant's SSN (last four digits only)
If the defendant does not have a Social Security Number or you do not know it please enter xxxx

Defendant's Phone Number

Defendant's Home Address

Does the defendant require the services of an interpreter?

Yes (Language):

Current Criminal Case Numbers and Related Charges
Please ensure you have entered valid case numbers to avoid delays in processing

Does the Defendant have any pending charges in any other jurisdiction?
This includes any County, State, or Federal charges. If yes, please specify jurisdiction and case number.

Yes

Do any of the following apply to the defendant?

History of treatment for mental illness

History of treatment for substance abuse

Diagnosed with a mental illness but has not received treatment

Diagnosed with a substance abuse disorder but has not received treatment

Suspected of undiagnosed mental illness

Suspected of undiagnosed substance abuse

None of these apply

Is the defendant currently in treatment?

Yes

I'm Not Sure

Has the defendant been a participant in this or any Drug Court?

Yes

Please briefly list where the defendant is currently receiving treatment and/or where they have received treatment in the past along with estimated dates.

I have reviewed the relevant program eligibility criteria prior to submitting this referral.

Yes, I have reviewed the relevant program eligibility criteria. I understand that the defendant must sign a Release of Information for each program s/he is referred to in order to complete the screening and assessment process. Releases may be found on the respective program web page.

Please note that your referral will be screened according to this criteria and any supporting records or documentation should be submitted to: ehutchison@ca.cjis20.org

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