HENRY COUNTY SUPERIOR COURT

Size: px

Start display at page:

Download "HENRY COUNTY SUPERIOR COURT"

Wendy Day
8 years ago
Views:

1 Date: HENRY COUNTY SUPERIOR COURT REFERRAL FORM FOR IN-PATIENT TREATMENT Referred by: Relationship: (Name) Contact Number(s): PARTICIPANT INFORMATION: (Lawyer, Probation Officer, Jail staff, DA or Solicitor s office, family member, etc.) Alternate #: Name: DOB: Case # Address: Telephone #: Alternate #: Is the person being referred currently in jail? Incarceration date, if known: { } Yes { } No Next court date: Has the person been sentenced by a Judge? { } Yes { } No Court(s) of Jurisdiction: List the current charges: List other programs and/or facilities where the client has received treatment: Reason for Referral: DATE FUND COMMITTEE USE ONLY Date Received: Evaluation Date: Status of Referral: Date of Panel Decision: Panel s Decision: If denied, reason:

Incarceration date, if known: { } Yes { } No Next court date: Has the person been sentenced by a Judge?

2 IN THE SUPERIOR COURT OF HENRY COUNTY STATE OF GEORGIA STATE OF GEORGIA, vs. Case No:, Defendant. DRUG ABUSE TREATMENT AND EDUCATION FUND ENTRANCE INTO SUBSTANCE ABUSE REHABILITATION CENTER CONTRACT You are voluntarily entering into this Contract. Please read the terms of this contract carefully, and initial each term of the contract, sign and date the contract. I,, understand that I have been permitted, in the above-captioned matter, to participate in the Drug Abuse Treatment and Education ( D.A.T.E ) Fund Entrance Into Substance Abuse Rehabilitation Center, and that I must fully comply with the treatment recommendations and other court orders set forth. I also understand that if I fail to comply with said treatment and/or court orders, such violations may subject me to sanctions and/or termination. 1. I will comply with all rules and regulations of the Rehabilitation Center. 2. I will take my medications as prescribed. 3. I will enroll and complete any inpatient/outpatient program as ordered. 4. I will attend the court ordered number of AA/NA meetings, as applicable, per week and submit proof of attendance as required. 5. I agree to attend all group and/or individual counseling sessions to which I am assigned. I will be on time for all sessions. Attendance is mandatory, but attendance alone will not satisfy the requirements for successful completion of the program. Poor participation, inattentiveness, chronic lateness, violation of the abstinence requirements, or failure to attend my program assignments will result in my return for judicial review. 6. I will not use alcohol in any form. 7. I will stay away from establishments where the primary business is the selling of alcohol. 8. I will not use any illegal drugs. I will not take over-the-counter medications without the written permission of my counselor, or physician, as some over-the-counter medications may produce a positive reading on drug screens and contain substances such as codeine.

Please read the terms of this contract carefully, and initial each term of the contract, sign and date the contract.

3 9. I will give a breath, blood, urine, hair or sweat sample, as required, for drug testing and may be responsible for payment for such service. 10. I will submit to a search of my person, place of residence, place of business, motor vehicle, papers and/or personal effects at any time of the day or night, with or without a search warrant or probable cause, and I specifically consent to the use of anything seized as evidence in any action to revoke an order of probation or in any subsequent criminal prosecution. 11. I stipulate as an expressed condition of my probation that any and all drug screening records used by the probation office/treatment provider reflecting results pertaining to me shall be admissible at any court hearing pertaining to me, if relevant to the issue pending, without the need of laying further foundation and expressly waive any and all objection to such records including, but not limited to, hearsay, chain of custody, and qualification of experts or examiners. 12. I understand that as a part of treatment services, all treatment providers will be requested, with my permission, to provide the Court with any necessary reports concerning my diagnostic intake, involvement and participation in assigned classes, assigned counseling or treatment programs, or any non-compliant status. I further understand that access to this information, as well as weekly progress updates, are a condition of my participation. 13. I will not violate the law. However, if I do violate the law, I will report it immediately to the Court. 14. I will be gainfully employed unless the Judge approves otherwise. 15. I will support any legal dependents that I may have to the best of my ability. 16. I will avoid people or places of disreputable or harmful character. This includes people currently on probation or parole and people with felony convictions, drug users and drug dealers. 17. I will follow all other program rules. 18. Failure to satisfy any of the previously stated terms of this agreement will result in my case being returned to the Court for appropriate action(s). 19. I understand I am to reimburse Henry County for the IDTA funds used to pay for my rehabilitation up to $3,600. Payments will be paid through Henry County Adult Probation and a monthly reimbursement rate will be determined by Henry County Adult Probation. Requests for payment adjustments (based on ability to pay) can be made through probation and/or the courts.

probable cause, and I specifically consent to the use of anything seized as evidence in any action to revoke an order of probation or in any subsequent criminal prosecution. 11.

4 20. The defendant/participant identified herein covenants and agrees to save, defend, indemnify and hold Henry County, Georgia, and each of its Departments, elected officials, judges, managers, officers, agents, employees and successors and assigns, ( Indemnified Parties ) harmless from any and all injuries or loss, including consequential damages, claims, liability claims, judgments, awards, liens, settlements, causes of action, damages, injury and expenses (including attorney fees) of every kind and nature whatsoever, resulting from, arising out of, or in any way related to, directly or indirectly, participation in this program. This indemnification will survive the expiration or termination of this Order by lapse of time or otherwise. Signature of Defendant Date Signature of Defense Counsel Date

awards, liens, settlements, causes of action, damages, injury and expenses (including attorney fees) of every kind and nature whatsoever, resulting from, arising out of, or in any way related to,

5 IN THE SUPERIOR COURT OF HENRY COUNTY STATE OF GEORGIA STATE OF GEORGIA, vs. Case No:, Defendant. It is hereby ordered that the Defendant successfully complete drug treatment at the facility designated by the IDTA Program. The defendant will reimburse Henry County for the IDTA funds used to pay for his/her rehabilitation up to $3,600. The Defendant s rate of pay will be determined by the Henry County Adult Probation; and may be adjusted based on ability to pay. This day of, 20 Judge, Henry County Superior Court.

The defendant will reimburse Henry County for the IDTA funds used to pay for his/her rehabilitation up to $3,600.

6 IN THE SUPERIOR COURT OF HENRY COUNTY STATE OF GEORGIA STATE OF GEORGIA, vs. Case No:, Defendant. Order for Immediate Incarceration It is further ordered that should the Defendant violate the terms and conditions of the, as determined by the director of said institution, said Sheriff of Henry County is directed to immediately pick up said Defendant and place them in the common jail of Henry County until further order of the Court. So Ordered this day of. 20 Judge, Henry County Georgia

as determined by the director of said institution, said Sheriff of Henry County is directed to immediately pick up said

Information to Potential Participant

22 ND JUDICIAL DISTRICT DRUG COURT Information to Potential Participant The Drug Court Program is a privilege you may exercise only once. To take part in this program, you must do the following: Complete