SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE BLYTHE 265 N. Broadway, Blythe, CA 92225 INDIO 46-200 Oasis St., Indio, CA 92201 PEOPLE OF THE STATE OF CALIFORNIA MURRIETA 30755-D Auld Rd., Ste. 1226, Murrieta, CA 92563 RIVERSIDE 4100 Main St., Riverside, CA 92501 FOR COURT USE ONLY RI-CR012 NOT TO BE FILED or IMAGED vs. DEFENDANT: CASE NUMBER: VETERANS COURT PROGRAM REFERRAL Misdemeanor Fax No: (951) 777-3716 A. Client Name: Client Address: Attorney Name: B. Attorney Phone No.: Referral Eligibility (MANDATORY- To be completed by attorney): Please check applicable boxes and enter the data requested. Is there a history of substance abuse? Methamphetamines Opiates Cocaine Branch of Service: Marines Army Navy Military Status: Active Honorable Discharge General Under Honorable Conditions General Under Other Than Honorable Conditions Dishonorable or Bad Conduct Discharge Service Start Date: Service End Date: Air Force Coast Guard Alcohol Marijuana Other: # of children: # of children living at home Ages of children: Educational Background: High school Some college Associates degree Living Situation: Sober Living Own Home/Apartment With a Friend/Relative Employment: Yes No Retired Homeless Other: Bachelor's degree Graduate degree Vocational degree Yes No DOB: Gender: Marital Status: Single Married or Domestic Partnership Divorced Social Security No.: Male Female If yes, please indicate substance(s) used and preference (1, 2, & 3): Felony Current Charge(s): All Information is required: Complete sections A, B, C, and D. Fax or e-mail the completed form to Heather Wood: E-mail: Heather.Wood@riverside.courts.ca.gov. Client Phone No.: Identification Information (MANDATORY- To be completed by attorney): Approved for Mandatory Use Riverside Superior Court RI-CR012 [06/23/14] VETERANS COURT PROGRAM REFERRAL Local Rule 4042 Riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 DEFENDANT: CASE NUMBER: VETERANS COURT PROGRAM REFERRAL Have you ever been diagnosed with a service related condition? If yes, check all that apply: PTSD TBI Depression Are you eligible for VA benefits/services? Are you enrolled in either Medical or Medicaid? Do you have any other type of health coverage? Please indicate why veteran is being referred: Yes No Yes No Yes No Substance Abuse Other: Race: American Indian or Alaska Native Black or African American Asian Pacific Islander or Native Hawaiian Other Multiracial Ethnicity: Hispanic/Latino Unknown White Unknown Non-Hispanic Other C. Assessment: The Veteran will be contacted by a VA Justice Outreach Specialist before the eligibility hearing. If out of custody, enter the contact number below: Contact Information: Facility: Booking Number: If in custody, enter the facility and booking number: D. Veteran's Signature: I understand that this information is intended to be used to screen me for eligibility for the Riverside County Veterans Court and does not guarantee my acceptance into the program. Furthermore, I understand that demographic information contained on this form (including race and ethnicity) will be used for statistical reporting purposes only and will not affect eligibility for the Veterans Court program. Date: Signature: Eligibility Court Hearing: Please calendar your client's case within 7 days of the referral date in Veterans Court, held on Wednesdays (for odd case numbers) and Fridays (for even case numbers at 1:30 pm in Department 31 (RVC). Approved for Mandatory Use Riverside Superior Court RI-CR012 [Rev. 06/23/14] VETERANS COURT PROGRAM REFERRAL Page 2 of 2 Local Rule 4042 riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com