Davis County MHC Application

Mental Health Court Application ^New

Full Name *

Email *

Date of Birth *

Phone Number *

Home Address *

Street, City, State, ZIP

Case Number(s) *

Please include all active Davis County case numbers

Defense Attorney Name *

If there is not a defense attorney, please enter NA

Do you live in Davis County? *

If no, what county do you live in? *

Are you homeless? *

Have you previously participated in the Mental Health Court program in Davis County or in any other County/Jurisdiction within the last 10 years? *

Do you have a mental health diagnosis? *

Mental Health Diagnosis *

Are you prescribed and taking any medications? *

Medications prescribed *

Are you currently serving a commitment on another case? *

Do you have any open/pending cases including pending OTSC in other Jurisdictions? *

If yes, what is/are the case numbers?

Have you ever been convicted of an offense that involved the use of a gun or other dangerous weapon or caused serious bodily injury? *

Do you have any outstanding warrants? *

Have you ever been convicted of a felony sex offense, or a registerable misdemeanor sex offense? *

Are you currently on probation or parole? *

Name of probation/parole agent