Community Corrections Facility

Defendant Referral Form

Referral Date:
Facility Name:	Lubbock County Community Corrections Facility
Defendant Description
Name:
(First Name)	(Middle Name)	(Last Name)	(Suffix)
Place of Birth:	Date of Birth:	Age:
Ethnicity:	Race:
Weight:	pounds	Height:	feet inches
Hair Color:	Eye Color:	Sex:
Driver’s License:	DL Status:	DL State:
State ID:	ID Status:	ID State:
Social Security:	Education:
FBI Number:	English Skills:	Speaks Reads Writes
SID:
Offense Information
Current Offense:
Cause/Case:	Offense Type:
TRN:	TRS:
PID:	OID:
Offense Date:	Arrest Date:
Weapon Used?:	Weapon Type:
Sentence Date:	Incarceration Sentence Length:
CSR Hours:	hours	Supervision Sentence Length:
CSCD/County:	Supervision Sentence Expires:
Judge Name:	CSO Name:
CSO Phone:	CSO Email:
Employment Information
Is the defendant able to work full time?	No Yes
If no, please explain:
Is the defendant currently employed?	No Yes
If no, please explain:
List the defendant’s employment history starting with the most recent.
Company	Duties	Length Employed
Criminal History
Does the defendant have any pending charges or outstanding warrants?	No Yes
If yes, please explain:
Is the defendant on community supervision or parole for another offense?	No Yes
If yes, please explain:
Does the defendant have a history of violence or assaultive offenses?	No Yes
If yes, please explain:
Substance Abuse
List the substances the defendant has used, the frequency, the amount, and the date he or she last used.
Substance	Frequency	Amount Used	Date Last Used
What is/are the defendant’s drug(s) of choice?
Type of last substance abuse screening (SAE, SASSI, ASI, etc.):
Date of last substance abuse screening:
Results of the last substance abuse screening:
Has the defendant completed other treatment programs (inpatient or outpatient)?	No Yes
If yes, list below the dates, lengths, and names of treatment programs completed.
Miscellaneous
Defendant’s Risk Score:	Defendant’s Needs Score:
SCS Score:	LSI-R Score:
Does the defendant have dependants?	No Yes
Is the defendant required to pay child support?	No Yes
List the conditions of community supervision the defendant has NOT completed. (GED, CSR, etc.)
Why is the defendant being referred to a CCF? (i.e. Substance Abuse Evaluation, SASSI, ASI, etc.)
CSO comments or other pertinent information:
Date	, CSO

Health Information for CCF Admission
Name:	Exam Date:
Social Security:	Driver’s License:
Sex:	Date of Birth:	Age:
Ethnicity:	Race:
Allergies
List Allergies (Drug, Food, and Environmental)
Allergy Type	Substance Name	Type of Reaction
Miscellaneous
Has the defendant recently had any unexplained weight loss or gain?	No Yes
If yes, please describe:
Does the defendant smoke cigarettes or use other tobacco products?	No Yes
When was the defendant’s last tetanus immunization?
Medications
List all medications (both prescription and over-the-counter), supplements, & herbs the defendant takes.
Medication Name	Dosage	Frequency	Reason for Medication
Family History
If any family member has had any of the following disorders, please mark that disorder and list the family member’s relation to the defendant in the column to the right of the disorder.
Disorder	Relation	Disorder	Relation
Alcoholism	Heart Disease
Arthritis	Hypertension
Bleeding Disorder	Kidney Disease
Cancer	Mental Illness
Diabetes	Mental Retardation
Drug Addiction	Stroke
Epilepsy/Seizures	Thyroid Disease
Current Conditions
Please mark any of the following that the defendant currently has.
Anemia	Broken Bone	Bronchitis	Constipation
Diarrhea	Frequent Colds	Frequent Headaches	Hemorrhoids
Vomiting	Pneumonia	Recent Fall	Sinusitis
Sexually Transmitted Disease(s):
Current & Past Conditions
Please mark any of the following that the defendant currently has or has had in the past.
Alcohol Abuse	Dialysis	Hepatitis	Recent Surgery
Allergies	Dizziness	Hernia	Seizures
Arthritis	Drug Abuse	Herpes	Serious Accident
Asthma	Eating Disorder	High Cholesterol	Serious Injury
Back Problems	Emphysema	HIV/AIDS	Severe Headaches
Bleeding Disorder	Epilepsy	Hospitalization	Shortness of Breath
Blood in Stool	Fainting	Hypertension	Sickle Cell Anemia
Cancer	Gallbladder Issues	Kidney Disease	Sleep Disorder
Heart Trouble	Glaucoma	Leg Cramps	Slurred Speech
Cataracts	Gonorrhea	Memory Loss	Stroke
Chest Pain	Gout	Mental Retardation	Syphilis
Chronic Cough	Head Injury	Nausea	Thyroid Disease
Coughing up Blood	Hearing Loss	Numbness	Tuberculosis
Dental Priority	Heart Disease	Bone Problems	Ulcers
Dentures	Heart Murmur	Pacemaker	Vascular Disease
Diabetes	Heartburn	Paralysis	Wheezing
Mental Illness(es):
Please explain any of the items marked above:
Does the defendant have any other health issues not included above?	No Yes
If yes, please explain:
Males Only
Does the defendant have or has he had any prostate problems?	No Yes
If yes, please explain:
Females Only
Is the defendant postmenopausal?	No Yes
Is the defendant pregnant?	No Yes
If yes, the due date:
Has the defendant been experiencing any missing periods?	No Yes
If yes, for how long:
When was the defendant’s last menstrual cycle?
When was the defendant’s last pap smear?
When was the defendant’s last breast exam?

Medical Clinician Report (To be filled out by a medical doctor, RN, LVN, or other medical clinician)
Weight:	Height:
Blood Pressure:	/	Pulse:
Respirations:	Temperature:
Does the defendant have special dietary needs?	No Yes
If yes, please explain:
Is the defendant’s activity level restricted?	No Yes
If yes, please explain:
Does the defendant have any physical restrictions?	No Yes
If yes, please explain:
Is the defendant required to have a lower bunk bed?	No Yes
If yes, please explain:
Is the defendant cleared for kitchen work?	No Yes
If no, please explain:
Please indicate the following marks on the body outline below.
Codes for Body Outline
A = Abrasion	L = Laceration	P = Piercing	ST = Stitches
B = Bruise	N = Needle Marks	R = Rash	T = Tattoo
BR = Burn	O = Open Sore	S = Scar
Does the defendant have any skin issues or infestations of the skin?	No Yes
If yes, please explain:
Does the defendant have any dental problems that require immediate attention?	No Yes
If yes, please explain:
Screening Tests
Tuberculosis Skin Test	Test Date:	Read Date:
Results:
TB Questionnaire	Test Date:
Results:	Symptomatic	Non-Symptomatic
TB Chest X-ray	Test Date:
Results:
If any treatment has been recommended, the X-ray was abnormal, or the skin test indicates infection, please attach tuberculosis record.
Hepatitis	Test Date:
Results:	Negative	Positive for type:
HIV Antibody	Test Date:
Results:	Negative	Positive CD4:
Syphilis	Test Date:
Results:	Negative	Positive for type:
Treatment Completed:	No Yes
General Observations or Recommendations:
Clinician Printed Name	Clinician Title
Clinician Signature	Date
Defendant Verification of Accuracy & Release Authorization
I, , have reviewed this entire document for accuracy and completeness. I verify that the information I have provided and the information the document contains regarding my present medical condition and my medical history is correct and complete to the best of my knowledge. I authorize this information and document to be released to the Lubbock County Community Corrections Facility.
Defendant’s Printed Name	Defendant’s Signature	Date