Application To Sami Court, Drug Court (C.d.a.t.), Or Felony Non-Support Docket (Fns) Form

ADVERTISEMENT

*Do not file with Clerk of Courts- submit this application to the Specialty Courts Office, 3
Floor, General Services Center, 315 High Street,
rd
Hamilton, OH 45011
APPLICATION TO SAMI COURT, DRUG COURT (C.D.A.T.),
OR FELONY NON-SUPPORT DOCKET (FNS)
Defendant’s Name: ___________________________________________
Date: ______________________
Case # (‘s): _________________________________, _______________________________________________
Charges and Degree F/M (w/level):___________________________________________________________
Next Court Date: ____________________
Trial Court Judge: ____________________________________
DOB: __________________ SSN: ________________ Defense Attorney: ____________________________
Defendant’s Address (City / State): ___________________________________________________________
Defendant’s Phone #: ________________________________________________________________________
#1 Drug of Choice: ______________ how much/ how often: ___________ Date last used: __________
#2 Drug of Choice: ______________ how much/ how often: ___________ Date last used: __________
Current / Previous Drug and/or Alcohol treatment (i.e. inpatient, residential, outpatient, etc.)
______________________________________________________________________________________________________
______________________________________________________________________________________________________
CHECK WHICH COURT(S) APPLYING FOR:
Drug Court:
If the offender has filed a Motion for Intervention in Lieu of Conviction with the Butler County Clerk of Courts,
in order for a pre-sentence investigation and substance abuse assessment to be completed, a signature by the
Trial Court Judge is needed to acknowledge that he/she has been informed of said motion; and that the
offender is to be assessed for the Butler County Drug Court Program.
Trial Judge Signature_________________________________
Date: _______________
The offender’s signature is also needed to grant permission for the Adult Probation Department to begin a
pre-sentence investigation to help determine the offender’s final eligibility for the Butler County Drug Court
Program.
Defendant’s Signature _________________________________
Date: ________________
SAMI Court:
circle all that apply
Does the offender have a mental health history including any of the following (
): multiple
hospitalizations, taking medications, guardianship, non-compliance with treatment, not taking medications,
involuntary hospitalizations, community probate, suicide attempt(s)? Yes / No
Mental Health Agency: __________________________ Psychiatrist: ________________________________
Mental Health Diagnosis: _____________________________________________________________________
Felony Non-Support Docket:
Does the offender have a current child support order (not arrears only)? Yes / No
Referral Source Signature:___________________________________

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go