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