Jericho Project Referral Form

For people charged with crimes in Shelby County who are in custody with a serious mental illness but medically stable.

If you are a private attorney, please submit this form to refer your client to Jericho. If not are not an attorney but would like to refer someone, please email us at jericho@shelbycountytn.gov, and we will be in touch.
Attorneys: please choose one of the following statements and sign or initial below.
Attorney Signature or Initials
Client Information
RNI
GS or Criminal Court Docket Number
GS or Criminal Court Division
OMSe Booking Number
Location
How did client hear about Jericho?
Client Name

First NameMiddle NameLast Name
Client Social Security Number
Client Permanent Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Client Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client Cell
Please enter a valid phone number.Format: (000) 000-0000.
Client Email
example@example.com
Client Gender
Client Race
Client Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Attorney & Clinical Information
Attorney Name

First NameLast Name
Attorney Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Attorney Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Attorney Cell
Please enter a valid phone number.Format: (000) 000-0000.
Attorney Email
example@example.com
Diagnosis
Diagnosis Confirmed by
Current Psych Medications
Current Psych Medications Confirmed by
Current (Last) Treatment Center
Current (Last) Treatment Center Confirmed by
Prior Treatment Center(s)
Prior Treatment Center(s) Confirmed by
Current (Last) Case Manager
Substance Abuse
Income Amount and Source
Representative Payee
Insurance
Policy Number
Additional Client Contact
Primary Contact Name

First NameLast Name
Primary Contact Relationship
Primary Contact Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Contact Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primacy Contact Cell
Please enter a valid phone number.Format: (000) 000-0000.
Primary Contact Email
example@example.com
Client Eligibility
Valid ID or ability to obtain ID or birth certificate
Veteran Status
If Veteran, Type of Discharge
Sex Offender Registration Required
Case & Program Purpose
Charges
Maximum Potential Sentence
Purpose of Jericho Project Community Linkage Plan

Other
Purpose of CLP - Other (specify)
Reason Attorney Seeking Jericho Project CLP (Goal)
Assistant District Attorney General Name
Attorney General Position on CLP
Other Pending Cases (including VOP)
Mental Evaluation
Mental Evaluation Status
Mental Evaluation - Date Received

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mental Evaluation - Date Requested

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mental Evaluation - Reason Not Requested
Mental Evaluation Results
Mental Evaluation - Mentally Ill (specify)
Other Significant Information
Should be Empty:

For people charged with crimes in Shelby County who are in custody with a serious mental illness but medically stable.

Client Information

Attorney & Clinical Information

Additional Client Contact

Client Eligibility

Case & Program Purpose

Mental Evaluation