• Veteran's Court Diversion Application

  • Format: (000) 000-0000.

  • Date of Birth

  • Sex*
  • Marital Status*

  • Dependents

  • Dependent

  • Dependent

  • Dependent

  • Dependent

  • Job Background

  • Unemployed?*

  • Present or Most Recent Job

  • Format: (000) 000-0000.

  • Military Service

  • Are you eligible for VA benefits?*
  • Highest Level of Education*

  • Counseling History

  • Have you ever participated in substance abuse counseling/treatment?*
  • Have you ever participated in anger control/batterers intervention?*
  • Have you ever participated in mental health treatment/hospitalized for mental illness?*
  • Have you ever been diagnosed with any major depressive disorder, polytrauma, military sexual trauma (MST), post-traumatic stress disorder (PTSD) or traumatic brain injury?*
  • If so, is it connected to military service?

  • Previous Criminal/Traffic Offense Record

  • Have you ever been arrested as an Adult or Juvenile?*
  • Have you ever been charged with a crime or received a citation as an Adult or Juvenile?*
  • Have you ever been convicted of a crime as an Adult or Juvenile?*
  • Have you ever had a conviction expunged from your record as an Adult or Juvenile?*
  • Have you ever had a case dismissed, diverted or an SIS for a crime as an Adult or Juvenile?*
  • Have you ever been charged or convicted of a crime in military court?*
  • Have you ever received a Non-Judicial Punishment/Art. 15?*

  • If you answered YES to any questions above, you must describe (if more than three offenses, please attach separate document with additional information):

  • Offense

  • Offense

  • Offense

  • I declare, verify, certify, or state under the penalty of perjury under the laws of the State of Kansas, that I have personally read or have had read to me the above application for Diversion and responses thereto and that all information contained in the forgoing application for Diversion, including but not limited to my listing of previous criminal record in section 5, is true and correct. I understand that if any of this information is not true and correct, this will be a basis for denial or revocation of Diversion. I agree that if an undisclosed criminal offense or DUI is discovered after Diversion has been granted, a criminal justice report, KBI report, Police Department or Sheriff's Office report, and/or Department of Revenue report may be admitted as evidence in any court, without foundation, to prove prior traffic or criminal offenses for the purpose of revocation of Diversion in this matter.

  • I hereby authorize the District Attorney's Office to release any information in the District Attorney's file pertaining to this offense for which I am charged to Johnson County Mental Health Center, the Department of Veteran's Affairs, the investigating Law Enforcement Agencies, or any other such person or agencies for use in determining whether I am a suitable candidate for diversion. I further authorize any person, agency, or organization to release and provide, upon request, any information to the office of the District Attorney in consideration of any application for Diversion.

    I further authorize any person, agency, or organization that is conducting an evaluation or treatment as part of the diversion application or the diversion agreement to release information to any other person, agency, or organization as needed for the evaluation or treatment process.

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