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2. Todays Date*
   Todays Date
3. Is client in custody?*

   1. Yes
   2. No
5. First Name*
6. Middle Name*
7. Last Name*
8. Date of Birth*
   Date of Birth
10. Address*
12. City*
13. State*
14. Zip Code*
15. Phone Number*
19. Case 1:
20. Is this a DV?*

    1. Yes
    2. No
22. Case Number*
23. Charge*
25. Prosecutor*
26. Defender*
28. Case 2:
29. Is this a DV?*

    1. Yes
    2. No
31. Case Number
32. Charge
34. Prosecutor
35. Defender
39. Reasons for the referral: (Check all that apply)*

    1. Possible suicide risk/danger to others
    2. Possible inability to care for self in or outside of the jail setting
    3. Possible evidence of mental disorder (e.g., psychosis, depression)
    4. Possible evidence of substance dependence/abuse IN ADDITION TO mental disorder
    5. Other
41. Add relevant details:*
42. Diagnosis (if known)*
44. Brief summary of the presenting problem:*
46. Referred by:*

    1. Judicial Officer
    2. Treatment Provider
    3. Prosecuting Attorney
    4. Law Enforcement
    5. Jail Mental Health Staff
    6. Defense Attorney
    7. Probation
    8. Jail Corrections Staff
    9. Other
48. Who?*
52. Sworn Declaration
    1. I swear or affirm under penalty of perjury under the laws of the State of Washington that all of the information above is true.
54. Referring Party - Type your full name here to e-sign.*
55. Referring Party's Firm/Agency*
57. Referring Party - Phone Number*
58. Referring Party - E-mail*
60. REQUIRED FOR DEFENSE ATTORNEY REFERRALS

62. ***PLEASE E-MAIL A FULLY COMPLETED AND SIGNED RELEASE OF INFORMATION TO:

     CHRISTINE.CROUCH@CO.YAKIMA.WA.US***

Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

* indicates a required field