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Collier County Treatment Courts Referral Form
* Required
Email Address
Please choose the program you wish the defendant to be screened for.
Adult Drug Court
Adult Mental Health Court
Adult Veterans Court
Referral Source Information
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
Probation
Private Citizen or Family Member
Self-Referral
Other:
Defendant Information
Defendant's Name
Defendant's Date of Birth
Month Year
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Sa
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Cancel
OK
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
This section is used for tracking and reporting purposes only
Defendant's Gender
Male
Female
Prefer Not To Answer
Defendant's Race
African American
Alaskan Native
Asian / Pacific Islander
Caucasian
Multi-Racial
Native American
Prefer Not To Answer
Other:
Is the Defendant of Hispanic, Latino, or Spanish Origin?
Yes
No
I'm Not Sure
Prefer Not To Answer
Is the Defendant In Custody?
Yes
No
I'm Not Sure
Do any of the following apply to the defendant?
Has served in the US Military (regardless of discharge reason)
Is a current or former US Department of Defense contractor
Is a current or former military member of a foreign allied country
None of these apply
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.
No
Yes:
Treatment Information
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
Has been diagnosed with mild traumatic brain injury related to military service
None of these apply
Is the defendant currently in treatment?
Yes
No
I'm Not Sure
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.