ADULT POST-ADJUDICATORY DRUG COURT EXPANSION PROGRAM APPLICATION PLEASE PRINT NEATLY PROGRAM OVERVIEW

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1 PROGRAM OVERVIEW The is open to Offenders with sentencing scores of 60 points or less, who are prison bound, and have committed a non-violent third-degree felony. This Program is an alternative to going to prison. [Florida Statutes , , , and addresses this postadjudicatory treatment based drug court program.] The Program uses a non-adversarial team approach that promotes public safety while protecting participants' due process rights. It is a treatment-based, closely-monitored 4-Phase Program. The Program has two implicit goals: the Offender Client becoming a drug-free, better-living member of society and the overall reduction of prison cost. It can be a win-win for both the Offender Client and the State. The following summary, although not totally inclusive, highlights the Program requirements. We encourage you to read the summary, discuss it with your attorney and family, and consider enrolling in this life-changing, highly beneficial prison alternative. Eligible participants are identified early and given one opportunity to voluntarily enter the adult postadjudicatory drug court expansion program; Drug court programs provide access to a continuum of alcohol, drug, and other related treatment and rehabilitation services; It is a post-adjudicatory program. You will be on Florida Department of Corrections Probation and/or Community Control throughout the entire Program. Violations could result in a prison sentence; You will have mandatory meetings to include court appointments, 12-Step [AA/NA/CA] meetings, group and individual counseling sessions, and random drug testing throughout the program; Program consists of 4 graduated phases over a minimum of 72-weeks. Phase I, II, and III are each a minimum of 16-weeks in length. Phase IV is a minimum of 4-weeks; Requirements in Phase I, II and III are extensive requiring trips to the downtown courthouse area 3-5 times a week. You will require transportation; The $50 per week Program Cost to you, the Offender Client, is very affordable and is spread-out over the Program length at no (0%) accrued interest; Drug court programs integrate alcohol, other drug treatment services, and ongoing judicial interaction with each drug court program participant is essential; Abstinence is monitored by frequent testing for alcohol and other drugs; The Program uses both reward incentives and graduated sanctions to encourage compliance; Finally, completing all the Program s requirements allows you to stay out of prison, and continue working, all-the-while, beginning a new, healthier lifestyle. If you believe this Program is for you, please sign below stating that you read and understand the above Program Overview and complete the attached Application and return it to this Office for processing. If you have any further questions please call this Office. Thanks and good luck! Printed Name (Last, First, MI) Signature Date Page 1

2 GENERAL: Name: Last First: Date of Birth: Race: SSN#: Address (1): City Address (2): City MI: Zip Code Zip Code Telephone #: (Home) (Cell) (Work) Sex: Female Male Marital Status: Single, Married, Divorced, Separated, Living as married, Other: EMERGENCY CONTACT: Name: Telephone #(s): Relationship: Name of Child(ren) List all other persons residing with you: Drivers License #: State: Make/Model of Vehicle(s) Owned/Leased: Date of Arrest CURRENT CHARGES (list all): Court Case #(s): Do you have any pending charges in another county? Yes No If yes, name of County Charges Date of Arrest CRIMINAL HISTORY List charges City/State Page 2

3 ANNUAL FAMILY INCOME: (circle one) (1) $0-$5,999 (2) $6,000-$10,999 (3) $11,000-$15,999 (4) $16,000-$20,999 (5) $21,000-$25,999 (6) $26,000-29,999 (7) $30,000-$49,999 (8) $50,000-$ (9) $60,000-$75,000 (10) Over $75,000. SOURCES OF INCOME: (check all that apply): Employment Pension Social Security Disability Worker s Compensation SSD SSI Spouse AFDC Other (describe) EDUCATION: Years of Education Completed: GED, High School Community College, College Graduate School Technical/Vocational, Business School Other TRADE(s) OR SKILL(s): (1) General Labor (2) Janitorial/Cleaning (3) Manufacturing (4) Food Service (5) Warehouse/Shipping (6) Retail Store (7) Office - Clerical (8) Office Professional (9) Driver (10) Medical (11) Trade, Craft, Skill 12) Sales (13) Other: MILITARY SERVICE: Yes No VA ELIGIBLE: Yes No Dates of Military Service: EMPLOYMENT HISTORY: List all employment for the past 5 years: Dates Employed Employer Occupation City & State Current Employment Status: Full-Time Part-Time Unemployed Not in labor force Current Employer s Name: Address of Employer: City Zip Code Telephone #: Length of time with current employer: Reason for leaving last employment: Page 3

4 DRUG HISTORY: Drug(s) Used Method (IV, Oral, Smoke Snort) Frequency Age Began Last Use 1 ST Drug of choice:, 2 nd Drug of choice: 3 rd Drug of choice:, 4 th Drug of choice: Comments: Used needles in the last year. Substances/drugs used by participant s spouse, partner, housemate or others living with participants. If yes, describe: DRUG TREATMENT HISTORY: (Treatment attempts prior to drug court): Prior treatment/counseling for drug/alcohol abuse: Yes No If Yes, Complete the below box: Type of Treatment 1 Treatment Provider Name of City/Town Began Ended Outcome (Completed/Reason for Leaving ) 1 Choose all that apply. (1) 12 Step (2) Offender (3) Drug/Alcohol (4) Detoxification (5) Methadone Maintenance 6) Out Patient (7)Psychotherapy (8)Residential (9)Other: Page 4

5 MENTAL HEALTH HISTORY: Have you ever undergone a mental health evaluation or treatment? Yes No Unknown If Yes, add any comments on the treatment, evaluation outcome or diagnosis: Date(s) evaluation: Dates of Treatment: From: Therapist/Hospital or Facility s name and location: Reason for treatment: List any medications prescribed during treatment: MEDICAL HISTORY: To: Describe your current health status: Are you currently under the care of any physician: No Yes If yes, provide physician(s) name(s) and address(es) in the below box: Physician Name Address Telephone Number Reason for Treatment Do you suffer any from any chronic illness, disease or condition? No Yes If yes, indicate the illness or condition and describe current treatment being received if any: If pregnant, month of pregnancy: List any disabilities: List any and all prescribed or over the counter medications you are currently using Childhood Diseases: Past Surgeries: Page 5

6 I acknowledge that I have a substance abuse problem and hereby request to be considered for the Adult Post-Adjudicatory Drug Court Expansion Program. I understand the opportunity to participate in this Program is a privilege, not a right. I acknowledge that if I am accepted, there will be rules and responsibilities that I will be expected to follow. I understand that I can expect to receive incentives when I progress in the program and sanctions when I do not. I further hereby grant permission to disclose and deliver to the treatment provider(s) and Drug Court Personnel, State Attorney, Public Defender/any private attorney retained on my behalf, any and all information contained in this application and any subsequent records from any Marion County Court. Such information may include my criminal history, medical, mental health, and psychiatric record information. This information is used in reference to decisions related to my involvement and participation in the Adult Post-Adjudicatory Drug Court Expansion Program. SIGNATURE DATE WITNESS PRINTED NAME WITNESS SIGNATURE DATE NOTE: IF HAS NOT BEEN COMPLETED IN IT S ENTIRELY IT MAY NOT BE PROCESSED. Name/Title: FOR REFERRING AGENCY/ATTORNEY Agency/Firm: Mailing Address Telephone Number(s) Facsimile Number: address Page 6

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