Recovery Monitoring Solutions - Forms
New Referral
* indicates a required field
Referring Agency*
Referring Agency 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
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
Click Browse to choose file
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
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
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
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
Urine Screening
Frequency per Month
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1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Type of Test
- Select -
Dip Stick
Double On-Site
Double Panel Lab Test
Ecstasy
ETG
ETG (Screen only)
Hair Test
Oral Swab
Poly Screen Lab Test
Single On-Site
Single Panel Lab Test
Spice
Triple On-Site
Triple Panel Lab Test
Substances
Amphetamines
Benzodiazepine
Creatinine
THC
Barbiturates
Cocaine
Opiates
Volatiles (Alcohol)
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
Submit to RMS