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Version 6.2.25 Honorable James G. Blanchard Jr. LaTeisha A. Mosquera Senior Judge, Superior Court Accountability Courts Coordinator Telephone (706)447-6761 REFERRAL REQUEST FORM Program of Interest: ☐ Drug Court: Traditional Track (Pre-Adjudication) ☐ Drug Court: Probation Track (Post-Adjudication) ☐ Mental Wellness Treatment Court ☐ Veteran’s Treatment Court Date of Referral: Defendant’s Name Date of Birth Social Security Number - - Gender Race Referral Source/Attorney: Phone Number Physical Location of Defendant for Contact: Incarcerated ☐ County Bonded ☐ ( ) Street Address City, State Zip Code Phone Number What is the physical address where the Defendant will live, if accepted into the program? Physical Address City, State II. CURRENT CHARGES Date of Charge Pending Case Number Type of Charge III. PRIOR CHARGES Date of Charge Case Number Type of Charge I. DEFENDANT INFORMATION Columbia Judicial Circuit Felony Accountability Courts ---PAGE BREAK--- Version 6.2.25 1. Does the Defendant have a mental health diagnosis? ☐ Yes ☐ No a. If so, please provide proof of diagnosis from treating doctor or facility (mental health records will be requested, if client is found eligible) 2. Has the Defendant ever been hospitalized for mental health and/or substance use disorder? ☐ Yes ☐ No a. If so, please provide proof of services from the facility (additional records will be requested, if the client is found eligible) 3. Is this a transfer case request? ☐ Yes ☐ No a. If yes, please include the entire file with the application to include the original charge and discovery. 1. What year did your client enter the U.S. Armed Forces? 2. Which branch? Reserve? National Guard? 3. If not currently serving, what year was your client separated from the U.S. Armed Forces? 4. Type of separation (Refer to DD Form 214, block 23. *Attach form)? 5. Character of service (Refer to DD Form 214, block 24. *Attach form)? For consideration, please complete and email to: E. Grace Jolly, Assistant District Attorney Email: [EMAIL REDACTED] LaTeisha Mosquera, Accountability Courts Coordinator Email: [EMAIL REDACTED] Please forward any medical records to: Franshon Hollis, Accountability Court Treatment Provider (Dr. D.W. DeVose and Associates) Email: [EMAIL REDACTED] IV. RECORDS REQUEST V. VETERAN’S TREATMENT COURT (FOR CONSIDERATION PLEASE COMPLETE)