Jasper County Recovery Court Application Form (Page 2 of 4) in pdf

Jasper County Recovery Court Application Form Page 2

JASPER COUNTY RECOVERY COURT APPLICATION FORM

Defendant’s Name______________________________________________________________

Date Received

____________

Defense Attorney ______________________________________________________________

Internal Use Only

Date of Birth: ________________________________SSN: _____________________________

Current Address: ______________________________City:_____________________________

County: __________________________State: ________________ Zip: ___________________

Phone Number: _____________________________

Alternate Phone Number where Defendant can be reached: ______________________________

Case Number(s):_________________________________________________________________

Charge(s): __________________________________Division case is pending: ________________

Has Defendant signed the Consent for Disclosure form for the Jasper County Treatment Court?

Yes: ______________ No: ________________

Is Defendant currently receiving or has Defendant in the past received substance abuse treatment?

Yes: ______________ No: _______________

Is Defendant currently receiving or has Defendant in the past received mental health services?

Yes: ______________ No: _______________

Has the Defendant served in the Armed Forces, in active combat, and received an Honorable Discharge?

Yes:______________ No: ________________

Please return this form and the release form to the Jasper County Court Services Officer

in person at 601 S. Pearl, Joplin, MO or by fax at 417-782-7172 or email to Matt.Ouren@courts.mo.gov

Jasper County Recovery Court Application Form Page 2