New Referral

Referring Agency*

Referring Agency State*

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

Client Zip

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

Case Number

Charges

Number of Days to be Served

If known

Testing Schedule

For Remote Breath or as needed

Urine Screening

Frequency per Month

Type of Test

Substances

Hold down CTRL (Windows) / COMMAND (MAC) key and click to select/de-select multiple entries

Drug Patch

UPS Referral

Number of Hours to be Completed

Deadline for Hours to be Completed

MM/DD/YYYY format required

Case Number

Offense