Fillable Circuit Court Mental Health Court Referral and Pre-Screening (Montgomery County Maryland)

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Circuit Court Mental Health Court Referral and Pre-Screening (Montgomery County Maryland)

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The Circuit Court Mental Health Court Referral and Pre-Screening (Montgomery County Maryland) form is 2 pages long and contains:

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  • 32 other fields

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File type: PDF

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Circuit Court Mental Health Court Referral and
Pre-Screening Form
Date:
Defendant's Name: DOB: SID #:
Montgomery County Resident: Yes No
Case Number(s) and Charge(s):
Location of Defendant: MCCF MCDC Other (Please specify)
Referral Made By (Include name and contact information):
Defense Counsel (Include name and contact information):
Please answer the following to the best of your ability regarding the defendant for whom you are making the referral:
Mental health diagnosis: Yes No Please specify:
Current/Past medications: Yes No Please specify:
Prior mental health Yes No Please specify:
treatment:
Prior mental health Yes No Please specify:
hospitalizations:
Please specify: History of substance Yes No
abuse:
Please provide any additional information that may assist with the screening and assessment of this defendant for
eligibility and acceptance into Circuit Court Mental Health Court.
Please email or fax completed form to:
Jenna Davis
Problem Solving Courts Coordinator
Email: jdavis@mcccourt.com
Fax: (240) 773-3913
Office: (240) 777-9141
RELEASE OF INFORMATION FOR ADMISSION TO MENTAL HEALTH COURT
LIMITED RELEASE TO BE USED SOLELY TO DETERMINE ELIGIBILITY FOR MENTAL
HEALTH COURT
CLIENT NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
GENDER:
1. The clinical team of the Mental Health Court of Montgomery County has my permission
to review and verbally discuss my mental health treatment.
2. My records obtained and information obtained from this release are to be kept by the
Health and Human Services Mental Health Court team and are to be used solely for the
purpose of determining eligibility for participation in mental health court.
3. If I am accepted into mental health court the records can be used by the mental health
court in determining and providing my treatment.
4. Any information obtained by this release may NOT be used against me by the State’s
Attorney or Court outside of the Mental Health Court.
5. This information is being shared solely to determine my eligibility into the mental health
program.
6. This authorization will be terminated upon my not being accepted into mental health
court, or, if accepted, upon completion of mental health court.
I understand that this release is valid when I sign it, and that I can withdraw this release at
anytime, but that withdrawal of the release may affect my eligibility for mental health court.
Signed:
Date:
Attorney:
Female
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Circuit Court Mental Health Court Referral and Pre-Screening (Montgomery County Maryland)

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Completed 6 May 2021

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