ADULT MENTAL HEALTH APPLICATION Adult Mental Health Court Diversion Application CASE INFORMATION Case Number * (001-80000-2017) Add Case Number Remove First Name * Middle Name Last Name * List all prior names, maiden name, former or current aliases, etc. * N/A if Not Applicable Defense Attorney Name * Last Name, First Name Defense Attorney Phone Number * (555) 555-5555 Defense Attorney Email Address * john@doe.com PERSONAL INFORMATION Date of Birth * Gender * Choose OneMaleFemale Race Choose OneAmerican Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther Race Ethnicity Choose OneHispanic or LatinoNon Hispanic or Latino Height Weight Eye Color Choose OneBlackBlueBrownGreenGray Hair Color Choose OneBaldBlackBlonde or Strawberry BlondeBrownGray or Partially Gray Address * Street or P.O. Box City * State * TexasOther State Zip Code * Home Phone Number 555-555-5555 Cell Phone Number * 555-555-5555 Drivers License Number * Drivers License Issuing State * TexasOther Drivers License Issuing State Names of people who live in your home and their relationship to you: * MENTAL HEALTH Have you ever attended treatment for mental health * Yes No If yes, indicate below all that apply. Hospitalization Outpatient therapy Both What was your diagnosis? If you are currently taking prescribed mental health medication list it below. Provide dosage/frequency and prescribing physician. SUBSTANCE ABUSE HISTORY Checkboxes Alcohol Heroin LSD Cocaine Marijuana Inhalants Crack Methamphetamine Other explain below List any drug use not shown above. Have you ever attended treatment for substance abuse? * Yes No If yes, indicate below all that apply. Hospitalization Outpatient therapy Both EDUCATION & EMPLOYMENT Highest Degree or Level of School Completed * Choose OneSome High SchoolHigh School Graduate or Equivalent (GED)Some College or Technical SchoolAssociate's Degree (AA, AS)Bachelor's Degree (BA, BS)Master's Degree (MA, MS, MEng, MEd, MSW, MBA)Professional Degree beyond bachelor's degree (MD, DDS, DVM, LLB, JD)Doctorate Degree (PhD, EdD)Other Highest Degree or Level of School Completed Are you a current student? * Yes No If yes, what school/university do you attend? What is your current grade/level? Current Employer Job Title Annual Income Employer Address (Street number, city and state) Employer Phone Number (555-555-5555) POLICE CONTACT: List all incidents in which you were cited, arrested, accused or charged with a crime other than a traffic violation. Include incidents that were set aside, referred to pre-trial diversion or pardoned. (Provide full explanation including incident date, location, police agency and disposition or court action) Juvenile Police Contact * Adult Police Contact * Have you EVER had pre-trial diversion intervention, granted deferred adjudication, probation or have been convicted for any offense other than a Class C misdemeanor? * Yes No If yes, please provide details: Please review your answers carefully and read the following statement before submitting this application! CERTIFICATION: I hereby certify that there are no willful misrepresentations, omissions, or falsifications in the foregoing statements and answers to questions. I understand that any omission or false statements on this application shall be sufficient cause for denial of admittance into the Collin County Adult Mental Health Court. Attach Program Agreement as mentioned above. * Drop a file here or click to upload Choose File Maximum file size: 516MB Signature * Clear Upon successful submission of this application, the defense attorney will receive an email confirmation. Please add (DA_AMHCDoNotReply@collincountyda.com) to your address book to avoid the email confirmation going into a spam folder. If you are human, leave this field blank.
