San Mateo County Mental Health/Probation Services Initial Referral for Screening for Veterans Treatment Court Return to: Adult Probation, 400 County Center, 5th Floor Redwood City, CA 94063 ATTN: Michael Leon FAX: (650) 363-4829 "CONFIDENTIAL PATIENT INFORMATION: See California Welfare and Institutions Code Section 5328" Veterans Treatment Court is a partnership of the San Mateo County Courts, Probation Department, District Attorney, Private Defender Program, Veterans Administration and Mental Health. Its purpose is to improve the outcomes for Veterans involved in the criminal justice system The criteria for eligibility include: Must have a prior or current membership in the United States Military Must be eligible for Veteran's Administration benefits Have a diagnosis of Post Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI), sexual trauma, substance abuse or other mental health issue that stems from military service. Must be eligible for probation Must not have a current offense that involves death, great bodily injury, permanent disability or disfigurement and/or deemed to be a danger to the community. Voluntarily agree to participate in Veterans Treatment Court and follow the Veterans Court treatment plan. This form initiates a screen for participation in Veterans Treatment Court. Please complete the information below and return it to the Probation Dept. at the address listed above as soon as possible. Follow up to this process can be done by contacting the individual's attorney. Defendant's Name Address, City, State Phone # Defendant's Attorney Attorney's Phone Number __________________________________ Court Case #'s In custody: Yes Today's Date: No Sheriff's I.D./Military ID number Date of Birth Pending charges Referred by:___________________________________________________________________ (please include name & phone number Self report Family_________________________ Veteran's administration Probation_______________________ Mental Health.________________ Defendant's Attorney_____________ Other __________________________ Reason for referral: ____________________________________________________________________________________ DO NOT WRITE BELOW THIS LINE Attorney Name__________________________________Date___________________________ Releases of information and Application attached: Yes No 04/18/12 American LegalNet, Inc. www.FormsWorkFlow.com