• Mental Health Diversion Application (Out of County)

  • Format: (000) 000-0000.

  • Date of Birth

  • Sex*
  • Marital Status*
  • Do you currently receive Medicaid/Medicare disability benefits?*

  • Present Job

  • Unemployed?*
  • Format: (000) 000-0000.

  • Previous Work Experience

  • Format: (000) 000-0000.

  • Educational Background

  • What is your highest level of education?*
  • Did you have an IEP/Special Education Services?*
  • Were you ever the subject of disciplinary action in school?*

  • Mental Health History

  • Have you ever participated in mental health treatment?*
  • Have you ever been hospitalized for mental illness?*
  • Have you ever participated in substance use counseling?*
  • Have you ever participated in substance use inpatient treatment?*

  • Medication History

  • Have you ever been prescribed a psychiatric medication?*
  • Are you currently taking psychiatric medications?*
  • At the time of this incident, were you taking any medications?*

  • 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?*

  • 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 havepersonally read or have had read to me the above application for Diversion and responses thereto and that all informationcontained in the forgoing application for Diversion, including but not limited to my listing of previous criminal record insection 6, is true and correct. I understand that if any of this information is not true and correct, this will be a basis fordenial or revocation of Diversion. I agree that if an undisclosed criminal offense or DUI is discovered after Diversion hasbeen granted, a criminal justice report, KBI report, Police Department or Sheriff’s Office report, and/or Department ofRevenue report may be admitted as evidence in any court, without foundation, to prove prior traffic or criminal offensesfor the purpose of revocation of Diversion in this matter.

  • Release of Information

  • I hereby authorize the District Attorney’s Office to release any information in the District Attorney’s file pertaining tothis offense for which I am charged to any mental health provider, DCF, and the investigating Law Enforcement Agencies, orany other such person or agencies for use in determining whether I am a suitable candidate for diversion. I further authorizeany person, agency, or organization to release and provide, upon request, any information to the office of the DistrictAttorney 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 thediversion application or the diversion agreement to release information to any other person, agency, or organization asneeded for the evaluation or treatment process.

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