Recovery Monitoring Solutions - Forms
New Referral
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Referring Agency*
Referring Agency State*
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Referring Officer*
Officer's Email*
Referral Site*
Referral Date
MM/DD/YYYY format required
Client Start Date
MM/DD/YYYY format required
Client Name*
Client DOB*
Client Phone*
Client Address
Suite/Apt#
Client City
Client State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Client Zip
Upload Client Photo
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Photo file must be selected prior to submitting to RMS. You will not be able to add a client photo after submitting referral to RMS.
Additional Info
Services Requested From RMS
Electronic Monitoring
Client Payment Agreement
0%
25%
50%
75%
100%
Client is responsible for percentage selected above of the required daily fees to be paid directly to RMS. The Referral Agency identified above will be responsible for the balance.
Type
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Active GPS
GPS/Remote Breath Combo
GPS/SCRAM Combo
House Arrest
House Arrest/Remote Breath Combo
Passive GPS
Remote Breath
SCRAM
SCRAM with ETHERNET base station
SCRAM with WIRELESS base station
SCRAM (CAM with House arrest)
Case Number
Charges
Number of Days to be Served
If known
Testing Schedule
For Remote Breath or as needed
SUN
MON
TUE
WED
THU
FRI
SAT
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
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8:00 AM
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3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
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1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
7:00 AM
8:00 AM
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11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
Hair Follicle Testing
Drug Patch
UPS Referral
Number of Hours to be Completed
Deadline for Hours to be Completed
MM/DD/YYYY format required
Case Number
Offense
Submit to RMS