Form Dc 3005 - Therapeutic Specialty Courts - Referral For Screening 2014
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District Court of Clark County
Therapeutic Specialty Courts - Referral for Screening
(check one)
MHC
VET
SAC
Date of Referral:
August 07, 2014
(Circle One if known)
Case Number (s): _________________ Charge (s):________________
Post / Pre Plea
_________________ Charge (s):________________
Post / Pre Plea
_________________ Charge (s):________________
Post / Pre Plea
Name of Client: __________________________________________________________
First
Middle
Last
Date of Birth:
Client Phone: ________________________
Client Address: ___________________________________________________________
Street
City
Zip
Name of Attorney:____________________________ Attorney Phone: ____________________
CLIENT:
Please CALL the Specialty Court Coordinator at 360-397-2431 to make arrangements
for a screening eligibility appointment. If you are incarcerated, Specialty Court staff will make
.
arrangements to come see you in the jail
I understand that if I do NOT attend that this may jeopardize the possibility of my participation
in this program. Additionally, I affirm that I have read the Specialty Court brochure.
Today’s Date: ____________________
August 7, 2014
Client Signature
Return to Court Date: _______________
at
Judge/Referring Agency: ________________________________________________
Judge of the District Court, Dept No_____
Print
*JA’s: Please pass the green copy on to the District Court TSC Coordinator ASAP.
(If accepted, attorneys will be notified of their clients Therapeutic Specialty Court docket date).
*BASIC ELIGIBILITY CRITERIA*:
1. Current charges must be misdemeanors or gross
3. You must:
misdemeanors
Pass a criminal background check
2. You CANNOT:
Be a Clark County, Washington resident.
Have prior sex offense that requires registration
Volunteer for the program
Serious violent criminal convictions – as defined
Admit to having a drug/alcohol addiction
by RCW 9.94A.030
and/or mental health diagnosis
Have any pending charges other than the case(s)
Want treatment
referred
Any outstanding warrants in any jurisdiction
Charged with and/or convicted of an offense in which
the defendant used a firearm
Distribution:
White- Court
Green- TSC Coordinator
Yellow- Prosecutor
Pink- Defense
Gold- Defendant
H:\FORMS\3-Specialty Court Forms\3005 - TSC Referral form.doc
DC 3005
Rev 06/14
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