Referral for CBI Diversion 042019

Justice Services Department

Referral to CBI Diversion Program
Date

MonthDayYear
Date
Participant's Name
DOB
Address
Contact #
To be completed by Referring Attorney:
Attorney Name (Printed)
Signature

Clear
Contact Number
Fax
Email
example@example.com
Participant to attend intake on: (See Flyer for available intake appointments) Reason for Referral: (Provide a detailed overview of why the participant is being referred including the charges and agreement made)
Participant to attend intake on: (See Flyer for available intake appointments)
I agree to participate in the CBI Diversion Program and understand the agreement mentioned above. I will attend the scheduled intake appointment.
Participant Signature

Clear
Date

MonthDayYear
Date
To be completed by the District Attorney's Office:
Assigned A.D.A Name (Printed)
Signature

Clear
Contact Number
Email
example@example.com
Compliance Date

MonthDayYear
Date
To be completed by JSD Staff:
Compliance Date

Attended scheduled intake appointment and scheduled to begin classes on: Failed to attend scheduled intake appointment or make contact within 30 days.To be completed by JSD Staff:
Outreach attempts
Justice Services Department

Send Referral Form and Consent Form to JSD Attention: Robin Heath

Fax: 919-560-0504 Tel: 919-560-0500
Consent for Communication of Confidential Information Among Cognitive Behavioral Intervention (CBI) Core Team Members
I,
hereby authorize the Justice Service Department's Cognitive Behavioral Intervention (CBI)

team members to disclose to, and receive information from the following parties:
- Presiding Judge
- Representative of the District Attorney's Office
Private Attorney
Other
The purpose of the disclosures is to inform the team members of my progress in the CBI program. The information disclosed may include my initial screening for the program, the case management assessment, case management plan, progress in the CBI program, notes, attendance, participation, attitude, additional evaluations or referrals.

Disclosure of this confidential information may be made only as necessary for, and pertinent to, hearings, and/or reports concerning the charges relevant to my participation in the CBI program. The docket number(s) for these charges are:

Charges

	Date Charged	Offenses	Charge Level (F=Felony or M=Misdemeanor)	Docket Number
Charge 1
Charge 2
Charge 3

I understand this consent will remain in effect for no more than one year and cannot be revoked by me until there has been a formal and effective termination of my involvement with the CBI program such as graduation, termination, or formal withdrawal.
Date

MonthDayYear
Date
Participant Signature

Clear
Revocation of Authorization
I do hereby request the authorization to disclose confidential information of
Client Name
signed by

Clear
Date

MonthDayYear
Date
Name of Person who signed Authorization
be rescinded for the person(s), organization, or others checked off below,
I understand that any action taken on this authorization prior to the rescinded date is
legal and binding.
Should be Empty:

Revocation of Authorization