Referral Form – Specialty Courts Notify Email:Where is your case located? Saint Lucie County Martin County Okeechobee County Indian River CountySaint Lucie County Programs: Adult Drug Court Adult Mental Health Court Adult Veteran’s Treatment CourtMartin County Programs: Adult Drug Court Adult Mental Health CourtOkeechobee County Programs: Adult Drug Court Adult Mental Health Court Adult Veteran’s Treatment Court Early Childhood CourtIndian River County Programs: Adult Drug Court Adult Mental Health Court Adult Veteran’s Treatment CourtReferral Source InformationReferral Source Name:Referral Source Phone Number:Referral Source Agency: Judge State Attorney’s Office Public Defender’s Office Office of Criminal Conflict and Civil Regional Counsel Private Defense Attorney Community Treatment Provider Probation Private Citizen or Family Member Self-Referral OtherOther Referral Source Agency:Defendant InformationDefendant's First Name:Defendant's Last Name:Defendants SSN (last four digits only):If the defendant does not have a Social Security Number or you do not know it please enter xxxxDefendant’s Date of Birth:Defendant’s Phone Number:Defendant's Address:Address Line 1:Address Line 2:City:State:Zip Code:Defendant’s Gender: Female Male Prefer Not to Answer OtherDefendant’s Race: African American Alaskan Native Asian / Pacific Islander Caucasian Multi-Racial Native American Prefer Not to Answer OtherWould the Defendant need an Interpreter? Yes NoPlease list the language:Is the Defendant of Hispanic, Latino, or Spanish Origin? Yes No I’m Not Sure Prefer Not to AnswerCurrent Criminal Case Numbers and Related Charges-Please list current criminal case numbers and any related charges within the 19th Circuit:Does the defendant have any pending charges in any other jurisdiction? Yes NoIf Yes, Please specify jurisdiction and case numberPlease specify jurisdiction and case number:Is the Defendant in Custody? Yes No I'm Not SureHas the defendant served in the US military? Yes NoCounty holding defendant: Saint Lucie County Martin County Okeechobee County Indian River CountyTreatment InformationSelect all that apply to the defendant? History of treatment for mental illness History of treatment for substance abuse Diagnosed with a mental illness but has not received treatment Diagnosed with a substance abuse disorder but has not received treatment Suspected of undiagnosed mental illness Suspected of undiagnosed substance abuse Has been diagnosed with mild traumatic brain injury related to military service None of these applyPlease briefly list where the defendant is currently receiving treatment and/or where they have received treatment in the past along with estimated dates:Is the defendant currently in treatment? Yes No I'm Not SureI have reviewed the relevant program eligibility criteria prior to submitting this referral. Yes, I have reviewed the relevant program eligibility criteria. I understand that the defendant must sign a Release of Information for each program s/he is referred to in order to complete the screening and assessment process. Submit Form
