Referral
HOCCS REFERRAL INFORMATION FORM For IGNITION INTERLOCK / HOME DETENTION / DAY REPORTING
Please complete form and send copies of the following:
1.) Charging Information _______ NEXT COURT DATE:__________
2.) If sentenced, court order ______ CAUSE NO:__________________
3.) Criminal History _______ JUDGE:_______________________
4.) Plea Agreement/Offer ______ (do not need BMV driving history)
CLIENT INFORMATION
NAME:____________________________________________________________
ADDRESS:_________________________________________________________
HOME/WORK:
D.OB.:_____________ RACE:_______ SEX: #of CHILDREN:_______
GED:________ HS. GRAD:__________ EMPLOYED:_________ UNEMPLOYED:.
REFERALL SOURCE INFORMATION
CIRCLE ONE: ATTORNEY /PROBATION /OTHER
NAME:______________________________________________________________
PHONE NUMBER:_____________________________ FAX:______________
INFORMATION ON CASE
PENDING CHARGE:_______________________________________
PLEA AGREEMENT: _______________________________________
CURRENTLY ON PROBATION: YES___________ NO _________
If yes, has a violation been filed for the NEW CASE?:_________
Does client have a drug or alcohol problem?:JYES___________ NO_________ If yes, is client in treatment? If yes, where?______________________________________________
OTHER CASES PENDING?:YES______________ NO_________ .
If yes, charge (s), and court(s)_____________________________________________
OTHER INFORMATION:
This information listed above and included information will be used to determine the appropriateness of placement into HOCCS alternative sentencing programs (Electronic Montitoring, Day Reporting, Ignition Interlock)
PLEASE FILL OUT COMPLETELY AND SUBMIT AT LEAST 2 WEEKS PRIOR TO NEXT COURT DATE
Please complete form and send copies of the following:
1.) Charging Information _______ NEXT COURT DATE:__________
2.) If sentenced, court order ______ CAUSE NO:__________________
3.) Criminal History _______ JUDGE:_______________________
4.) Plea Agreement/Offer ______ (do not need BMV driving history)
CLIENT INFORMATION
NAME:____________________________________________________________
ADDRESS:_________________________________________________________
HOME/WORK:
D.OB.:_____________ RACE:_______ SEX: #of CHILDREN:_______
GED:________ HS. GRAD:__________ EMPLOYED:_________ UNEMPLOYED:.
REFERALL SOURCE INFORMATION
CIRCLE ONE: ATTORNEY /PROBATION /OTHER
NAME:______________________________________________________________
PHONE NUMBER:_____________________________ FAX:______________
INFORMATION ON CASE
PENDING CHARGE:_______________________________________
PLEA AGREEMENT: _______________________________________
CURRENTLY ON PROBATION: YES___________ NO _________
If yes, has a violation been filed for the NEW CASE?:_________
Does client have a drug or alcohol problem?:JYES___________ NO_________ If yes, is client in treatment? If yes, where?______________________________________________
OTHER CASES PENDING?:YES______________ NO_________ .
If yes, charge (s), and court(s)_____________________________________________
OTHER INFORMATION:
This information listed above and included information will be used to determine the appropriateness of placement into HOCCS alternative sentencing programs (Electronic Montitoring, Day Reporting, Ignition Interlock)
PLEASE FILL OUT COMPLETELY AND SUBMIT AT LEAST 2 WEEKS PRIOR TO NEXT COURT DATE