ADSAP-Education-Treatment Referral Form (Non CMS) {ADSAP-102}

ADSAP/EDUCATION/TREATMENT REFERRAL FORM ENROLLMENT REQUIRED WITHIN 30 DAYS NON CMS A C O U R T Court: City/County: Referring Judge Name: Court Phone: ( ) Court Address: Court Fax: ( ) Court Email: Defendant Name: Address: Phone: ( ) City & State: Date of Birth: Ticket/Warrant # Driver's License # Driver's License State: Convicted of: DUAC: 1st Offense DUI: 1st Offense DUAC: 2ndOffense DUI: 2nd Offense rd DUAC: 3 Offense DUI: 3rd Offense th DUAC: 4 Offense DUI: 4th or Subsequent Date of Conviction: Indictment #: REFERRAL (Please check appropriate boxes) Defendant is to enroll within 30 days, attend and complete a South Carolina certified ADSAP (Alcohol Drug Safety Action Program) pursuant to SC Code of Law sections 56-5-2930, 56-5-2933 and 56-5-2990. Defendant is subject to contempt of this court if there is failure to enroll within 30 days. Defendant is required to attend and complete a SC certified ADSAP and comply with recommendations of ADSAP. SC Department of Probation, Parole and Pardon Services (SCDPPPS) to receive notification if there is failure to enroll, attend and complete a SC certified ADSAP and comply with recommendations of ADSAP if the defendant is currently on supervision for the referred offense. ADSAP Site: Agency Name Address: ADSAP Fax: ( (See site list.) B Enroll by Date: Phone Number: ( ADSAP Email: ) U S E C ) NON-ADSAP ASSESSMENT/TREATMENT PROGRAM REFERRAL (See site list.) Program Site: Reason for Referral: Address: City/State Zip: Other Instructions: Enroll by Date: ADSAP/OTHER PROGRAM REPORT Failed to Enroll Treatment Recommendations: Failed to Complete (Summary Attached) PRI Relapse Prevention Assessment Date: Outpatient Completion Date: (for SCDPPPS) Intensive Outpatient (Alternative Services) Inpatient Clinical Counselor (Signature) P R O G R A M D Clinical Counselor Name (Print) Date Defendant's Signature (If applicable) Date U S E E ADSAP COUNSELOR The counselor's signature indicates that treatment has been completed in accordance with South Carolina law and that the defendant is in compliance with the recommendations of the ADSAP program and order of the court. Clinical Counselor Name (Signature) Clinical Counselor Name (Print) Distribution: Original ­ Court; Copies ­ Defendant; ADSAP (and SCDPPPS if applicable) ADSAP Form 102 02/2009 Date American LegalNet, Inc. www.FormsWorkFlow.com