Outpatient Competency Restoration (OCR) Program
Acknowledgment
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I confirm that I have all the required documents ready to submit with this form, as per the instructions, to ensure the processing of my referral request. (If some of the documents are unavailable to you, please note below in“Other Comments”)
Date
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-
Month
-
Day
Year
Date
Referring court or agency
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Who should we contact if we have questions about this referral
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First Name
Last Name
Referral Source Contact Email Address
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example@example.com
Referral Source Contact phone number
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Please enter a valid phone number.
Who is ordering OCR take place? (e.g., Judge, Magistrate, or other Individual name)
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First Name of defendant to receive OCR services
Last Name of defendant to receive OCR services
Defendant Phone Number
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Please enter a valid phone number.
OCR Defendant’s Date of Birth
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-
Month
-
Day
Year
Date
OCR Defendant’s Preferred Gender
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Please Select
Male
Female
Transgender Female to Male
Transgender Male to Female
Doesn't identify as F, M, or Transgender
declined
Unknown
Where is the defendant residing at this time?
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Community?
Facility?
In a facility/institution (note name of facility in text box)
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number defendant
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Please enter a valid phone number.
Facility Phone Number
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Please enter a valid phone number.
Docket/Case No.(s)
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Is there anything else you would like us to know about this referral? (e.g., anything not mentioned above that you would like us to know)
Please note the ACTUAL hearing date pertaining to OCR. (ONLY answer if a hearing date has been scheduled. If none scheduled, note as TBD.)
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Who will we send the report(s) to? (e.g., judge, you as referral contact, probation, etc.)
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Name and phone number or email of family member, guardian, or other person to contact defendant, if applicable.
Defense Attorney Name (if none, type "N/A" in both boxes)
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First Name
Last Name
Defense Attorney Email Address
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example@example.com
Defense Attorney Phone Number
*
Please enter a valid phone number.
Prosecuting Attorney Name
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First Name
Last Name
Prosecuting Attorney Email Address
*
example@example.com
Prosecuting Attorney Phone Number
*
Please enter a valid phone number.
Other Comments about anything else you want us to know (e.g., You can add names and contact info for collateral sources or other colleagues.)
Is this a correction to a referral already filed?
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Yes
No
Please upload the required documents. For security reasons, please DO NOT EMAIL documents to individual CDTC staff members. If need be, we can also send you a shared folder link for transfer or accept/pick up recording materials.
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Certification:
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I certify that all information I provide on the referral form is accurate to the best of my knowledge
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