MHC Referral Form

326 East Main Street Durham NC 27701

Mental Health Court Diversion Program Referral
Client's Name
Date of Birth

MonthDayYear
Date
Referral Date

MonthDayYear
Date
Complete Address
Opus # (if applicable)
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Gender

MaleFemale
Custody Status

JailPTRROR
Bail

Yes
Bail $
Date Posted

MonthDayYear
Date
Referring Person
Referring Email Address
example@example.com
Referring Phone#
Client Attorney
Attorney Email Address
example@example.com
Attorney Phone#
CHARGE INFORMATOIN

Current Durham County Charge(s)

	Charge(s)	Docket Number	Date of Arrest	Felony/Misdomeanor
Charge 1
Charge 2

If so, indicate what jurisdiction(s) and the specific charge(S):

	Charge(s)	Docket Number	Date of Arrest	Felony/Misdomeanor
Charge 1
Charge 2

Indicate if a Competency Exam/Evaluation is being contemplated or if one has been ordered

YesNo
Mental Health Diagnosis (if known) or observations (Reason for Referral)
Drug/Alcohol Use

AlcoholMarijuanaCocaineMethamphetamineNot KnownOther
Treatment History
Attach supporting documents here

Cancelof

Consumer Name
DOB
Justice Services Department
Record Number
OPUS
I Consumer Name hereby authorized the Justice Services Department's Mental Health Court (MHC) program to disclose to, and receive information from the following members of the 1Justice Services Department's Mental Health Court Team:
> Presiding Judge
> Representative of the District's Attorney's Office
> Defense Attorney or Representative of the Public Defender Office
> Representative of the Division of Community Corrections
> Representative of the Division of Community Corrections
> TASC
> Representative of Treatment Program (s); (provider's name)
> Local Police/Sheriff Department
> Emergency Department (Duke, Duke Regional, UNC)
> Recovery Innovations
> Alliance Behavioral Healthcare
The purpose of the disclosure is to inform the Mental Health Court of my progress in the Mental Health Court Diversion Program. The information disclosed may include my initial screening for the program, the Comprehensive Clinical Assessment, case management plan, progress in the MHCDP, progress in treatment (that will include progress notes, attendance, participation, attitude, additional substance use or psychological testing or evaluations, or the need for outside referral for additional services.

Disclosure of this confidential information may be made only as necessary for and pertinent to, hearings, and/or reports concerning the charges relevant to may participation in the Mental Health Court Diversion Program.

The Docket Numbers for these charges are:

I understand that 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 Mental Health Court Diversion Program such as graduation, termination,

I understand that any disclosure made is bound by part 2 of Title 42 of the Code of Federal Regulations, which governs the confidentiality of substance use patient records, and that recipients of this information may re-disclose it only in connection with their duties relevant to the Mental Health Court Diversion Program.
Client Signature

Clear
Date

MonthDayYear
Date
Witness Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

CHARGE INFORMATOIN