Probation/CPS/Drug Court Referral Form
(e)info@miamivalleyrecovery / (p) 937-401-8672
Date
*
/
Month
/
Day
Year
Date
Client's Name
*
First Name
Last Name
Clients Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
/
Month
/
Day
Year
Date
Sex
*
Male
Female
Insurance
None
Medicare
Medicaid
Private
Is client living at home address?
YES
NO
If NO: What is the name of the facility where they are living?
If YES: Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race
*
Marital Status
Occupation
Current Offense
*
Current Status
*
Pre-Trial
Pre-Sentence
Probation
Serving Sentence
Other
Other Information Available
Is the client currently on probation/parole?
Yes
No
Unknown
Please UPLOAD Presentence investigation report (OR PREMISSABLE SECTIONS) and other needed information below
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Previous clinical evaluation or hospitalization?
Please check any court-ordered treatment you are requesting for this client
Substance Use Counseling
Mental Health Counseling
Dual Diagnosis Program
Assessment Only
Please state what treatments concerns you want addressed regarding this client.
Referral Agency
*
Referral Agent
*
First Name
Last Name
Referral Agent Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Agent Email
*
example@example.com
How often would you like to receive client progress reports?
Weekly
Monthly
Quarterly
As Requested
Additional Comments
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