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2. Client Name:*
3. Date of Birth*
   Date of Birth
4. Referral Dat:*
   Referral Dat:
6. Referred Cause Number(s):
7. Current Referring Charge(s):
9. Are there other pending charges:

   1. Yes
   2. No
10. If yes, identify charges/court:
12. Is the client currently:

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

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

    1. Yes
    2. No
18. Prosecuting attorneys Name:
19. Defense Attorneys Name:
21. Next Omnibus Hearing:
    Next Omnibus Hearing:
22. Next Trial Date
    Next Trial Date
26. Client Phone Number:
27. Address:
29. Alternate Contact Name:
30. Alternate Phone Number:
32. Client Address or other contact information
36. 1. Possible suicide risk and or danger to others.

    1. Yes
    2. No
37. 2. Possible inability to care for themselves outside of a controlled environment.

    1. Yes
    2. No
38. 3. Evidence of or history of mental health disorder.

    1. Yes
    2. No
40. 4. Evidence of or history of substance abuse in addition to a mental health disorder.

    1. Yes
    2. No
41. If yes, please indicate a diagnosis if known:
43. Please provide a brief summary of the presenting problem: *

47. 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:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field