COMMONWEALTH of VIRGINIA

Department of Corrections

Community Corrections - 114 Main Street Suffolk VA

Adult Probation and Parole

Referring Officer's Name *

Referring Officer's Email *

Client's Full Name

Client’s Social Security Number *

Important Information to Know:

◉ For my assessment, I will bring my valid state identification.

◉ If I cancel or no show, there is a $20.00 fee Cash and Personal Check are NOT accepted.

◉ I agree to attend all scheduled sessions and to follow GMA Interventions treatment recommendations until favorably discharged.

◉ If I receive more than (2) absences, I will be discharged and a review of my case for return to court.

◉ If I need to contact GMA, their phone number is 757-335-4234

DOC # *

MED Date *

Client's DOB *

Client's Phone Number *

Client’s Email Address *

Client Last 2 Urine Screens (Date/Results) *

Reason(s) for referral

Did above client have any positive drug screen(s)? *

Yes

Was there an admission of use? *

Yes

Was the above Court/Parole Board Order for? *

Assessment

Treatment

Both

None

Did the offender request for treatment? *

Yes

Does the above client have a Substance abuse history – list substances previously used *

Client Signature

Probation & Parole Officer Signature *

DCPO Officer Signature (If Client is approved for Telehealth)

Approved for funding *

Approved

Not approved for funding (Self Pay)

Signature *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.