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2. Client Name*
3. DOB*
   DOB
5. Cause #
6. Referral Date
8. Prosecutor
9. Defense Attorney
11. Current Charges
13. Next Omnibus Hearing
    Next Omnibus Hearing
14. Next Trial Date
    Next Trial Date
18. Client Current Contact Information
20. Custody Status?

    1. In Custody
    2. Out Of Custody
21. Telephone Number
23. Client Address or other contact information
27. Chemical Dependence Screening Tool
29. The following questions and your answers will only be given to the Drug Court Screener. Under no circumstance will any information be used against you. The information will help your attorney with the referral process into the Yakima County Drug Court.
31. 1. In the last 12 months, have you ever drank or used drugs more than you meant to?

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

    1. Yes
    2. No
33. 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
35. 4. Has anyone ever objected to your drinking or drug use?

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

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

    1. Yes
    2. No
39. Scoring = 0-Not appropriate for Drug Court 1 to 6-Refer to Drug Court Screener
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41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field