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ADAPT Mental Health Assessment Request
 
ACCELERATED Diversion And Progressive Treatment (ADAPT)


A community program for Chester County adults with serious mental illness arrested for criminal charges that do not pose a risk to public safety, to assist in accessing intensive mental health services in lieu of prosecution.

Click here for the ADAPT Program flyer. 

Human Services, Inc. provides assessment services for the purpose of providing mental health service planning and/or recommendations for Chester County residents who have severe mental illness and are in the criminal justice system. This referral form must be complete and submitted to the Bail Agency or Human Services, Inc. along with any additional information that is requested.

If you are not filling this form online, please print and fill out and return to:

Chester County Bail Agency
17 North Church Street, Courthouse Annex, Third Floor
West Chester, PA 19380
Phone: 610-344-6886
Fax: 610-344-6524

or

Human Services, Inc.
222 North Walnut Street
West Chester, PA 19380
Phone: 610-692-3415
Fax: 610-692-4703

Client Name:
Social Security #
Date of Birth
Address
Home Phone:
Cell Phone:
Name, address, and phone of attorney or other contact person
Your E-Mail Address:
required field
Current Criminal Charge(s)
Is the client currently incarcerated?
Yes No
If yes, where?
Is the client currently on probation/parole?
No Yes Unsure
Any other outstanding charges?
No Yes Unsure
If yes, please provide details:
Insurance:
None Medicare Medicaid Private Unsure
It is the responsibility of the referral source to notify the client of this referral.
Has the Client been notified?
Yes No
If no, why?
Name of person making the referral:
Agency and Phone:
Attach criminal complaint and psychiatric evaluation if available (PDF or Word):
Allowed extensions: doc,pdf,wpd,txt
Maximum Filesize: 524288 bytes
Auditory and/or visual hallucinations
Delusional thoughts
Manic behavior/speech, racing thoughts
History of psychiatric hospitalization
Irrational/bizarre behavior
Suicidal behavior
Debilitating depression
Self-injurious behavior
Does the person have substance abuse/dependence?
Yes No
required field = Required
Content is © 2008 Chester County Bar Association
Legal Disclaimer: http://www.chescobar.org/legal_disclaimer.html
Contact Information: 15 West Gay Street, Second Floor / West Chester, PA 19380 / Ph: 610.692.1889 / Fax: 610.692.9546
Printed: Sunday the 20th of July 2008 04:15:57 AM