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ADULT MENTAL HEALTH APPLICATION

Adult Mental Health Court Diversion Application

CASE INFORMATION

(001-80000-2017)
Add Case Number Remove
N/A if Not Applicable
Last Name, First Name
(555) 555-5555
john@doe.com

PERSONAL INFORMATION

Street or P.O. Box
555-555-5555
555-555-5555

MENTAL HEALTH

Have you ever attended treatment for mental health
If yes, indicate below all that apply.

SUBSTANCE ABUSE HISTORY

Checkboxes
Have you ever attended treatment for substance abuse?
If yes, indicate below all that apply.

EDUCATION & EMPLOYMENT

(Street number, city and state)
(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)

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.

Maximum upload size: 516MB

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.

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