Pre Screening Form

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MERRIMACK COUNTY / 6
CIRCUIT-DISTRICT DIVISION-CONCORD
MENTAL HEALTH COURT
PRE-SCREENING FORM
Please submit to: Mental Health Program Manager, Merrimack County Department of
Corrections, 314 Daniel Webster Highway, Boscawen, NH 03303 or Fax to: 603-796-3682
Check if DV
_________________________________________
__________________ 
Case 1
Defendant Name – Last, First, Middle Initial
_______________________
Charge
____________________
__________________
DOB
Referral Date
__________________ 
Case 2
_________________________________________
_______________________
Charge
Current Location (Inmate, Address, etc)
____________________
__________________ 
Case 3
Phone Number
_______________________
Charge
Hearing:
Pre-Trial
Arraignment
__________________ 
Case 4
Show Cause
_______________________
Charge
__________________
Other:
Reason(s) for the Referral: (Check all that apply)
Possible suicide risk/danger to others
g
Possible inability to care for self in or outside of the jail settin
Possible evidence of mental disorder (e.g. psychosis, depression)---
_
Other:
______________________________________________________________________
____________________________________
Brief summary of the presenting problem (Required):
____________________________________________________________________________
____________________________________________________________________________
Referred by:
Mental Health Court Judge
Police/Law Enforcement
Defense Attorney
Other Judge/Magistrate
Treatment Provider
Public Defender’s Office
Jail
Probation
Judicial Officer
Court Officials
Community Mental Health
Court Clerk
Private Citizen/Family
Treatment Provider
Self-Referral
Other: specify_________________________
__________________________________
_______________________________________
Referring Party – Please Print Name
Judge
___________________________________ _______________________________________
Referring Party’s Firm/Agency
Prosecuting Attorney
___________________________________ _______________________________________
Referring Party’s Telephone Number
Defense Attorney (If not referring party)
REQUIRED
***PLEASE ATTACH A FULLY COMPLETED AND SIGNED RELEASE OF INFORMATION***
Please note: An incomplete prescreen form may result in a rejection to Mental Health Court.
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MC / 6
CIRCUIT-DISTRICT DIVISION-CONCORD MENTAL HEALTH COURT PRE-SCREENING FORM – August 2011
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