Ccis Program Termination Form

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CCIS PROGRAM TERMINATION FORM
1. Offender Name: ____________________________________
2. Offender ID#: __________________
3. County Number: 63
4. Enrollment Date: _____/_____/____
5.
Program Code: (select one)
6. Date of Birth: _____/_____/________
Community Service
Pretrial Service
Placement
Screening/Assessment
A19
F22
Work Crew
A25
Supervision
F23
Other
A99
Other
F99
Education
Substance Abuse
Adult Basic Education
Detoxification
B01
G06
GED Completion
B09
Educational Awareness
G07
High School Completion
B10
Inpatient
G12
Life Role Competencies
B16
Intensive Outpatient
G13
B22
Screening/Assessment
Monitoring/Testing
G17
B99
Other
Outpatient
G18
Residential
G21
Employment and Training
Screening/Assessment
G22
C14
Job Seeking Skills
G99
Other
C15
Job Training
C19
Placement
Twenty-Four Hour Structured
C22
Screening/Assessment
H20-02
New Paths Inc.
Other
Huron House
C99
H20-14
Community Programs, Inc.
H20-19
Mental Health
Sequoia Recovery Services
H20-99
Day Activity
E03
Solutions to Recovery
H20-57
Inpatient
E12
Sobriety House
H20-58
Intensive Outpatient
E13
Brighton
H20-99
Outpatient
E18
Sequoia
H20-31
Residential
E21
Turning Point Recovery
H20-23
Screening/Assessment
E22
Case Management
6.
Program Funding Source:
Screening Assessment
(select one)
I22
CCAB Plans and Services
Other
1
I99
Probation Residential Center
2
7.
Termination Date: _______/_______/_______
Federal Substance Abuse Grant
3
Other
4
8.
Termination Reason:
(select one)
Successful Completion
1
Failed to comply with program requirements
2
Did not participate or complete
3
New Offense-Felony
4
5
New Offense-Misdemeanor
6
Failure to appear in court
7
Absconded
8
Relapsed
9
Other Reason
FORMS\AIC\AIC_02F.doc Rev. 03.26.2007

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