REFERRAL FORM

Referral Form

Recovery Court
General Court of Justice Services Department
GENERAL INFORMATION
Referral Date*

MonthDayYear
Date
Referral From:*

District Court JudgeDistrict AttorneyPublic Defender / Defense CounselSuperior Court JudgeProbation OfficerPre-TrialStarr ProgramOther
In Custody*

YesNo
Location DCDC*

YesNo
If No, Location
CLIENT PROFILE
Last Name*
First Name & MI*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Ethnicity*
Gender*

MaleFemale
Personal Telephone*
Please enter a valid phone number.Format: (000) 000-0000.
Work Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Attorney
Attorney Telephone
Please enter a valid phone number.Format: (000) 000-0000.
PPO*
PPO Telephone*
Please enter a valid phone number.Format: (000) 000-0000.
PPO Email*
example@example.com
CHARGE INFORMATION
New Case*

YesNo
Pending Charge*

YesNo
If Yes, Court Date

MonthDayYear
Date
Case Number(s)
Probation Violation / Modification*

YesNo
If Yes, Court Date

MonthDayYear
Date
OPUS Number

Charges

Referral Form