Chester County Probation, Parole & Pretrial Services

201 West Market Street, Suite 2100 West Chester, PA 19380-0989

610-344-6290

Chester County Veterans Court Referral Form

Please Note: You must submit the client's DD-214 form and criminal complaints. Documents can be attached at the bottom of this form

Client Information

Client Name

Date of Birth (MM/DD/YYYY)

Social Security Number

Phone Number

Are you currently incarcerated at Chester County Prison?

Yes

Date of Incarceration (MM/DD/YYYY)

OTN

Are you currently on parole or probation?

Current Criminal Charges

Do you have outstanding charges/detainers?

Where are your outstanding charges/detainers from?

Service History

Branch of Armed Forces (check all that apply)

Air Force, National Guard, Air Force Reserve

Army, Army National Guard, Army Reserve

Coast Guard, Coast Guard Reserve

Marine Corps, Marine Reserve

Navy, Navy Reserve

Other

Service Dates

Date Entered into Service

Discharge Date

Type of Discharge

Honorable

Dishonorable

General

Other

Have you ever received services at a VA hospital?

Yes

Have you ever served in any capacity in a combat zone?

Yes

Who is submitting this referral?

Client

Attorney

Someone else

Referral Information

Relationship to Client

Referrer Name

Referring Agency

Attach Client's DD-214 and Criminal Complaints

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