California > Local County > Riverside > Criminal
Veterans Court Program Referral RI-CR012 - California
| Veterans Court Program Referral Form. This is a California form and can be used in Criminal Riverside Local County . |
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SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE INDIO 46-200 Oasis St., Indio, CA 92201 MURRIETA 30755-D Auld Rd., Ste. 1226, Murrieta, CA 92563 PEOPLE OF THE STATE OF CALIFORNIA RIVERSIDE 4100 Main St., Riverside, CA 92501 RI-CR012 vs. DEFENDANT: CASE NUMBER: VETERANS COURT PROGRAM REFERRAL Misdemeanor Felony All Information is required: Complete sections A, B, C, and D. Fax or email the completed form to Pamela Miller: Fax No: (951)704-7568 Email: Pamela.Miller@riverside.courts.ca.gov A. Identification Information (MANDATORY To be completed by attorney): Client Name: Client Phone No.: Client Address: Attorney Name: Attorney Phone No.: B. Referral Eligibility (MANDATORY To be completed by attorney): Please check applicable boxes and enter the data requested. Is there a history of substance abuse? If yes, check the primary drug of choice: Methamphetamines Alcohol Opiates Marijuana Cocaine Other: Military Information: Yes No DOB: Married Male Social Security No.: Single Female Divorced Marines Air Force Army Coast Guard Navy Honorable Discharge General Under Honorable Conditions General Under Other Than Honorable Conditions Dishonorable or Bad Conduct Discharge Specific years served in military: Ethnicity/Race: No. of children: No. of children living at home: Highest level of education: Employed : Yes No Have you ever been diagnosed with a service related condition? If yes, check all that apply: PTSD TBI Depression Substance Abuse Other: Please briefly indicate why this individual is being referred: C. Assessment: The Veteran will be contacted by a VA Justice Outreach Specialist before the eligibility hearing. If in custody, enter the facility and booking number: If out of custody, enter the contact number below: Facility: Booking Number: Contact Information: D. Veteran's Signature: I understand that this information is intended to be used to screen me for eligibility for the Riverside County Veterans Court and does not guarantee my acceptance into the program. Date: Signature: Eligibility Court Hearing: Please schedule your client's case 7-14 days from the referral date in Veterans Court, held on Fridays at 1:30 p.m. in Department 31 (RVC). Approved for Optional Use Riverside Superior Court RI-CR012 [Rev 1/22/13] VETERANS COURT PROGRAM REFERRAL Local Rule 4042 riverside.courts.ca.gov/localfrms/localfrms.shtml Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com
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