Northampton County Treatment Continuum Alternative to Prison

Northampton County Treatment Continuum Alternative to Prison

Client Referral Form: Please complete the following form with as much information as possible. Send completed forms to or fax to (610)419-6061.

Name of person completing this form: / Phone Number:
Demographics
Offender Name: / Social Security #:
Date of Birth:
Last Known Address: Street, City, State, Zip
Current Location: Northampton County PrisonLehigh County PrisonAbove listed addressOther Other: Date of Incarceration:
Legal Information
Current Charges:
Prior Record Score: / Docket #:
SID (if known): / OTN:
Attorney: / Next Court Date:
Are they currently under supervision?
None
Pretrial Which County:
Probation State (PA)Northampton CountyOther County If other, where?

Step One: Presumptive Qualifying Characteristics

The offender committed a crime motivated by a desire to support an alcohol/drug habit.
The offender openly admitted that he/she is an alcohol/drug user.
The offender's family, friends, probation officer, etc. indicated that the individual is a drug/alcohol user.
The offender tested positive for alcohol/drugs at the time of arrest.
The offender tests positive for alcohol/drugs while on pre-trial release.

step two: disqualifying characteristics

Any item checked below disqualifies the individual unless the TCAP coordination team determines them to be eligible outside the guidelines below.
The offender is not a resident of Northampton County.
The offender is precluded by Pennsylvania’s Sentencing Guidelines.
The offender has a history of being convicted of a violent offense within the past 10 years.
The offender is currently under the supervision of the PA State Parole Board.
The offender has charges pending, active warrants, or is considered to be a fugitive in another county or state.
The offender has ever been charged and convicted of any sexual offense. (*Note: the 10 year rule does not apply to this)
Additional Information:

548 North New Street, 2nd Floor, Bethlehem, PA 18018

Fax: (610) 419- 6061

Lori Collins, BS Michael J. Krim, MA/CCDP Diplomate

Referrals and Admissions Case Manager

(610) 393-2990 (610) 393-2529