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2. Story County Alternative’s Program - Officer Referral Form
4. Full Legal Name*
5. Phone Number*
7. Address*
9. Address (Apt/Unit)
11. City*
12. State*
13. Zip*
15. Date of Incident*
    Date of Incident
16. Case Number
18. Officer Name*
19. Agency*
21. Officer Contact Info (phone number, email address)*
23. Information/summary about the incident and what led up to officer involvement: *
25. Step 1: Substance Identification*

    1. Known or Suspected Substance Use Disorder
    2. Individual reports current illegal substance use
    3. Observed indicators consistent with substance use
27. Step 2: Risk of Criminal Justice Involvement*

    1. Other Police encounters in the past year related to substance use
    2. Arrest in the past year related to substance use
    3. Risk of continued law enforcement involvement due to substance use
    4. No Prior Criminal Justice Involvement
29. Step 3: Charging Decision*

    1. Offer diversion in lieu of charges
    2. Charge and offer diversion
    3. Charge without diversion currently
    4. No Charge
31. Step 4: Charge Eligibility*

    1. Trespass
    2. Disorderly Conduct
    3. Public Intox
    4. Interference with officials acts (no injury)
    5. Drug possession (1st or 2nd offense)
    6. Possession of drug paraphernalia
    7. No Charge
33. Step 5: Reach out to Alternatives

    Nicholle Stangeland – Alternatives Program Manager, nstangeland@storycountyiowa.gov (515)509-6743

    Merrideth Spiers – Alternatives Program Coordinator, mspiers@storycountyiowa.gov (515)766-8767

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35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

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