Diversion Online Application – Montgomery County, KS

Type of Diversion *

Juvenile
Adult

Application Date

Personal Information

Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Age

City and State Where Born

Date of Birth (mm/dd/yyyy) *

Last 4 SSN # *

Confirm Email

Gender *

Female
Male

Martial Status

Single
Married
Divorced
Widowed

If Married, Spouse's Name

First

Last

Please list your dependents names and ages (if none - write N/A or none):

If you live with someone other than the persons listed above, list their names.

Employment

Are you employed? *

Present Job

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work Phone

Your Position

Date of Employment

Pay Type

Hourly
Bi-Weekly
Monthly
Annual

Salary Amount

Previous Employer

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Your Position

Date of Employment

Previous Pay Type

Hourly
Bi-Weekly
Monthly
Annual

Previous Salary Amount

Education Information

Highest Level of Education

Some High School
High School Diploma
Some College
College Degree

Counseling History - Have you participated in any of the following?

Substance Abuse Counseling or Treatment

Anger Control or Batterers Intervention

Mental Health Treatment or Hospitalized for Mental Illness

Please list your diagnosis

If you answered yes to any of the Counseling History questions, please provide more information.

Previous Criminal or Traffic Offense Record

Have you ever been arrested as a Juvenile or Adult?

Have you ever been charged with a crime or received a citation as a Juvenile or Adult?

Have you ever been convicted or a crime as a Juvenile or Adult?

Have you ever had a conviction expunged from your record as a Juvenile or Adult?

Have you ever had a case dismissed, diverted, or an SIS for a crime as a Juvenile or Adult?

If you answered yes to any of the Criminal or Traffic Offense questions in this section, please describe the offense, the date, the location, and the outcome.

If you answered no to all of the questions in this section, you must certify under penalty of perjury that you have no prior criminal record by checking this box.

No prior criminal record

Please state in your own words, and in detail, the facts of the CURRENT CASE which caused charges to be filed. *

Authorization

I declare, verify, certify, or state under the penalty of perjury under the laws of the State of Kansas, that I have personally read or have had read to me, the above application for Diversion, including but not limited to my listing of previous criminal record is true and correct. I understand that if any of this information is not true and correct, this will be a basis for denial ro revocation of Diversion. I agree that is an undisclosed criminal offense or DUI is discovered after Diversion has been granted, a criminal justice report, KBI report, Police Department, or Sheriff's Office report, and/or Department of Revenue report may be admitted as evidence in any court, without foundation, to prove prior traffic or criminal offenses for the purposes of revocation of Diversion in this matter. *

I understand and agree.

Release of Information

I hereby authorize the County Attorney's Office to release any information in the County Attorney's file pertaining to this offense for which I am charged to Four County Mental Health Center, DCF, and the investigating Law Enforcement Agencies, or any other such person or agencies for use in determining whether I am a suitable candidate for diversion. I further authorize any person, agency, or organization to release and provide, upon request, any information tot he office of the County Attorney in consideration of any application for Diversion. *

I understand and agree.

I further authorize any person, agency, or organization that is conducting an evaluation or treatment as part of the diversion application or the diversion agreement to release information to any other person, agency, or organization as needed for the evaluation or treatment process. *

I understand and agree.

By providing my electronic signature below, I agree and understand these statements. *

Please type your name.