Mo 650-8997 - Satop Comparable Program Completion
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1
2MISSOURI DEPARTMENT OF MENTAL HEALTH
Esta forma deberá llenarse por la agencia
CONTROLLERS OFFICE
donde recibió las clases.
SUBSTANCE ABUSE TRAFFIC OFFENDERS PROGRAM (SATOP)
PO BOX 596, JEFFERSON CITY, MO 65102-0596
PHONE: (573) 522-4020
SATOP COMPARABLE PROGRAM COMPLETION
Section I must be completed by OFFENDER and Sections II, III, and IV must be completed by
GENCY. Please print legibly.
I. OFFENDER INFORMATION
NAME (LAST, FIRST, MI)
SOCIAL SECURITY NUMBER
CURRENT MAILING ADDRESS
CURRENT TELEPHONE NUMBER
(
)
CITY
STATE
ZIP CODE
DATE OF BIRTH
DRIVER LICENSE NUMBER
STATE WHERE LICENSE ISSUED
MALE
FEMALE
II. OFFENDER COMPLETION INFORMATION
(IN ACCORDANCE WITH STATUTE RSMO 302.540 AND RULE AND REGULATION 9 CSR 30-3.206)
A) OUT-OF-STATE RESIDENTS
(Individuals must receive an assessment and complete the recommendation according to their states requirements)
DATE OF ASSESSMENT (MM/DD/YY)
NAME OF ASSESSOR OR ASSESSMENT AGENCY
_____ / _____ / _____
RECOMMENDATION (EDUCATION AND/OR TREATMENT)
DESCRIPTION OF SERVICE SUCCESSFULLY COMPLETED
BEGINNING DATE (MM/DD/YY)
ENDING DATE (MM/DD/YY)
_____ / _____ / _____
_____ / _____ / _____
B) MISSOURI RESIDENTS
(As of February 1, 2005, Missouri residents MUST complete a Missouri SATOP or Missouri Comparable Program.)
TREATMENT BEGINNING DATE (MM/DD/YY)
TREATMENT ENDING DATE (MM/DD/YY)
_____ / _____ / _____
_____ / _____ / _____
NUMBER OF TREATMENT HOURS SUCCESSFULLY COMPLETED
TOTAL HOURS
___ Individual Counseling
___ Group Counseling
___ Group Education
___ Driver-Related Education
___ Family Therapy
SATOP USE ONLY
III. AGENCY CERTIFICATION/ACCREDITATION
I hereby certify that this agency is state-certified and/or accredited by:
DEPARTMENT/DIVISION
CONTACT PERSON
STREET ADDRESS
TELEPHONE NUMBER
(
)
CITY
STATE
ZIP CODE
THIS AGENCY IS ACCREDITED BY
TJC
CARF
COA
IV. AGENCY AUTHORIZATION
I hereby certify that I am a representative of the agency listed below and am authorized to complete this form.
NAME (PLEASE PRINT LEGIBLY)
SIGNATURE (MUST BE SIGNED)
DATE
AGENCY
STREET ADDRESS
TELEPHONE NUMBER
(
)
CITY
STATE
ZIP CODE
(OVER)
MO 650-8997 (12-10)
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