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2. Client Name*
3. DOB*
   DOB
4. Referral Date*
   Referral Date
6. Referred Cause Number(s):
7. Current Referring Charge(s):
8. Estimated total restitution that will need to be paid:
10. Are there other pending charges?

    1. Yes
    2. No
11. If yes, identify charges/court:
13. Is client currently:

    1. In Custody
    2. Out of Custody
14. Are there any active outside holds?

    1. Yes
    2. No
15. Are there any active warrants?

    1. Yes
    2. No
17. Prosecuting Attorneys Name:
18. Defense Attorneys Name:*
20. Next Omnibus Hearing
    Next Omnibus Hearing
21. Next Trial Date
    Next Trial Date
25. Client Current Contact Information
27. Client Phone Number:
28. Address:
30. Alternat Contact Name:
31. Alternate Phone Number:
33. Client Address or other contact information
37. Chemical Dependence Screening Tool
39. The following questions and your answers will only be used to determine referral eligibility and help your attorney with the referral process. Under no circumstance will any of this information be used against you.
41. 1. In the last 12 months, have you ever drank or used drugs more than you meant to?*

    1. Yes
    2. No
42. 2. Have you ever neglected some of your usual responsibilities because of using alcohol or drugs?*

    1. Yes
    2. No
43. 3. Have you felt you wanted to or needed to cut down on your drinking or drug use in the last year?*

    1. Yes
    2. No
45. 4. Has anyone ever objected to your drinking or drug use?*

    1. Yes
    2. No
46. 5. Have you found yourself thinking a lot about drinking or drug use?*

    1. Yes
    2. No
47. 6. Have you ever used alcohol or drugs to relieve emotional discomfort such as sadness, anger, boredom or loneliness?*

    1. Yes
    2. No
49. Scoring = 0-Not appropriate for Drug Court 1 to 6-Refer to Drug Court Screener

51. Please send completed form to:

    Yakima County Superior Court Prosecutor: Susie Silverthorn

    Email: susie.silverthorn@co.yakima.wa.us

    Phone: (509)574-1210 Fax: (509)574-1211

Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field