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Social Services Assistance Request
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* Indicates required question
Client First Name:
*
Your answer
Client Last Name:
*
Your answer
Client's Date of Birth:
*
MM
/
DD
/
YYYY
Client Address:
Or other contact information
Your answer
Client Phone Number:
Your answer
Client Language Needs:
English
Spanish
Other:
Criminal Cause Number(s):
Your answer
Current Charge(s)
Your answer
What is the current plea offer?
Your answer
Custody Status?
*
In
Out
Is this case on or eligible for the Mental Health Docket?
Yes
No
Eligible
Clear selection
Next Setting
MM
/
DD
/
YYYY
Type of Setting
Your answer
Court Case Is Set In
Your answer
Urgency Level:
*
Low
Medium
High
Type of Referral:
*
Select all that apply
Mental Health Services
Substance Abuse Services
Record Collection
Mitigation
Competency Screening
Other:
Required
What are you hoping the social services team can accomplish with your client?
Your answer
Due Date:
MM
/
DD
/
YYYY
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