Treatment Form

Treatment Form
Acknowledgement:*

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.
Patient Full Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email*
example@example.com if no email, please assist the patient in creating a Gmail account while in your office. You may also use your work Email and all appointments reminders will be sent to you
Is patient living at home?*

YesNo
Facility Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Instant Offense (conviction for which the patient is being referred)*
Date of Charge or Conviction*

MonthDayYear
Date
Felony Level*
Count #*
List all original charges, counts, and dispositions for this Conviction or Charge (if Pretrial services)
List CURRENT medical, mental health or substance abuse services patient is receiving *
Gender Status*
Pronoun Preference*
Occupation*
Employment Status (Check all that apply)

Full-timePart-time1st shift2nd shift3rd shiftUnemployed
Work Schedule
Best days and times (M-F) to be seen for services
List all PAST treatment and hospitalizations (during the last 3 years)*
LCAPD ONLY: Is this a Court-Ordered Referal

YesNo
LCAPD ONLY: If No, list reason for referral
LCAPD ONLY: if yes, attach Court Order, Journal Entry, or other documentation as evidence of an order for services by a Judge

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List any additional requests for services *
Is the patient required to complete drug screens?*

YesNo
Frequency of Screenings*
List dates of positive screens, substances positive, and dates noncompliance.*
Has the client been awarded an Intervention in Lieu of Conviction? (Section 2951.041)*

YesNo
For LCAPD, please attach Criminal history to all referrals to assist us in assessment and treatment. At a minimum, all Anger Management, Batterer Intervention, and Sex Offender referrals (except direct-sentence) MUST have a Criminal History before the assessment can be scheduled. Please contact the office if none is available.
File Upload

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LCAPD ONLY: please attach the redacted PSI Report to all referrals to assist us in assessment and treatment. At a minimum, all Batterer Intervention and Sex Offender referrals (except direct-sentence) MUST have the redacted PSI Report before the assessment can be scheduled. Please contact the office if none is available.
File Upload

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Probation Officer information.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
PO Email*
example@example.com
Certification:*

I certify that all information I provide on the referral form is accurate to the best of my knowledge.
Should be Empty:

Treatment Form

Probation Officer information.