Fillable Kitsap County Therapeutic Courts

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Kitsap County Therapeutic Courts

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Kitsap County Therapeutic Courts
Participant Application
Preferred
☐
Behavioral Health
☐
Felony Diversion
☐
THRIVE
Court:
☐
Drug Court
☐
Veteran’s Court
Referred by:
☐
Defense Attorney
☐
Jail Mental Health
☐
Treatment Provider
☐
Therapeutic Court
☐
Law Enforcement
☐
Corrections Staff
☐
Contact Number:
Please return completed form to the Kitsap County Prosecuting Attorney’s Office:
• In person to our Receptionist
Received Date:
• By email at kcpa@co.kitsap.wa.us
• By fax at 360-337-4949
• By Mail:
614 Division Street, MS-35
Port Orchard, WA 98366
General Information
Application
Date:
NOTE:
The information provided on this form by the applicant, in pursuit
of acceptance into a therapeutic court, is protected under ER 410.
Name:
Date of Birth:
Address:
Contact Phone:
Email:
Cause No.
Defense Attorney:
Charges:
Has Omni Been Entered?
☐
No
☐
Yes*
In Custody?
*If yes, explain delay in applying for TC Court:
☐
No
☐
Yes*
*Booking Date:
Other Open
Cases:
(incl. diversion,
probation, DOC)
☐
No
☐
Yes*
*List charge(s), court(s), case status:
Out of State
History:
☐
No
☐
Yes*
*List charges, locations, dates:
Have you ever been granted a diversion or sentencing alternative in adult court?
☐
Yes
☐
No
When/Where:
Have you ever participated in any adult treatment court?
☐
Yes
☐
No
When/Where:
Have you ever applied to and/or been declined entrance into another treatment court?
☐
Yes
☐
No
Why:
Transportation Information
Do you have a current Driver’s License?
☐
No
☐
Yes
What is your current mode of transportation?
Housing Information
Do you need assistance with housing?
☐
No
☐
Yes
Explain:
Employment Information
Currently Employed?
☐
Yes:
Employer Name:
Contact Information:
Length of Employment:
Job Description:
Supportive of Recovery?
☐
No
☐
Yes
☐
No:
When were you last employed?
Employment History:
Previous Employer:
Dates of Employment:
Reason of Leaving:
Education Information
Highest Level of
Education Completed:
☐
GED
☐
High School
☐
Some College
☐
College Degree
Interested in further Education?
☐
No
☐
Yes, I would like to:
Military Information
Served?
☐
No
☐ Yes:
What branch:
Years of Service:
Participated in
VA Services?
☐
No
☐
Yes:
What VA services?
Do you have
access to your
DD214?
☐
Yes
☐
No:
What is your discharge status?
Chemical Dependency Treatment Information
Prior CD
Treatment?
☐
No
☐
Yes:
Where?
When?
Completed?
☐
Yes
☐
No
Where?
When?
Completed?
☐
Yes
☐
No
Substance
Use
History:
Drug(s) of Choice?
When did use began?
Method of ingestion?
Frequency of use?
Date of Last Use?
Preferred Treatment Agency
(if applying for drug court):
☐
Kitsap Recovery Center
☐
WestSound Treatment Center
☐
Agape Unlimited
Mental Health Treatment Information
Mental Health
Diagnosis?
☐
No.
☐
Yes, explain:
MH Diagnosis:
Date:
Provider/ Facility:
Previous MH
Diagnosis?
Mental Health
Treatment?
☐
No.
☐
Yes, explain:
Current Provider:
Dates:
Previous Provider:
Dates:
Previous Provider:
Dates:
Mental Health
Medications?
☐
No.
☐
Yes:
Current MH
Medications:
Previous MH
Medications:
Medical Information
Medical
Concerns?
☐
No
☐
Yes:
Medications &
Supplements?
☐
No
☐
Yes:
Active Health
Insurance?
☐
No
☐
Yes:
Insurance
Company:
Applicant Questions
For Drug Court, Veteran’s Court, Behavioral Health Court, and THRIVE applicants:
1.)
Thinking about your actions and decisions leading to the current charges, how did your substance use
diagnosis, mental health symptoms, military experience, and/or exploitation survival experiences contribute
to your behavior?
2.)
What life changes are you seeking to make by participating in Therapeutic Court?
3.)
What are you willing to do differently to accomplish these changes?
4.)
In what ways do you believe Therapeutic Court participation will help you achieve these changes ?
For Felony Diversion applicants:
1.)
What qualities make you a good candidate to successfully complete a Felony Diversion?
2.)
What are potential barriers to your success in Felony Diversion completion and how will you overcome them?
3.)
Thinking about your actions and decisions leading to the current charges, what effects did your choice have
on other people and how do you feel about those impacts?
4.)
What will you do differently if you are confronted with a similar situation in the future?
Revised 050120
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Kitsap County Therapeutic Courts

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Completed 1 March 2021

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