Read REFERRAL FORM FOR SCRAM PROGRAM text version

Monitoring Services LLC.

REFERRAL FORM FOR SCRAM PROGRAM

The SCRAM Bracelet is worn on the ankle and will, at pre-programmed intervals, tests for the presence of a blood alcohol concentration by the measurement of alcohol emitted as vapors through the skin. When the SCRAM Bracelet detects the presence of alcohol it will record a positive reading and will transmit an alcohol alert to the SCRAM Modem. The SCRAM Bracelet also contains systems designed to detect interference or tampering and will also transmit a tampering alert to the SCRAM Modem.

Date: __________

Case Number: ________________________

Your Name: ____________________________________________________________ Agency: ____________________________________________________________ Phone: ____________________________ Fax: ________________________ Email: ____________________________ Cell: ________________________

Client Name: (Last) _______________________ (MI) ___ (First) ________________ Social Security: _______________________ DOB: ________________________ Gender: Male: ___ Female: ___ Height: ______ Weight: _____ Address:________________________________________________________________ City: _________________________________ State: ______ Zip Code: _______ Home Phone: __________________________ Work Phone: __________________________ Cell Phone: __________________________ Alternate Contact: ______________ Alt. Phone: __________________ Relationship: __________________

Occupation: __________________________ Work Hours: __________________ Any special conditions that may be present in the clients work environment. i.e. alcohol based cleaners, fumes, etc: ________________________________________________________________________

Judge: _______________________________ County Attorney: ______________________ Attorney: ____________________________ Start Date on SCRAM: ___________________ Days on SCRAM: 30 ___ 60 ___

In Office Installation: ____________ Remote Installation: ____________

End Date: _____________________ 90 ___ Other ___

PLEASE EMAIL OR FAX THIS FORM TO OUR OFFICE Email: [email protected] Fax: 515-875-4895

309 Court Avenue Suite 242 Des Moines, IA 50309

p. 515-875-4814 1

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REFERRAL FORM FOR SCRAM PROGRAM

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REFERRAL FORM FOR SCRAM PROGRAM