Adsap Education Treatment Referral Form

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ADSAP/EDUCATION/TREATMENT REFERRAL FORM
CMS
ENROLLMENT REQUIRED WITHIN 30 DAYS
Court:
City/County:
Referring Judge Name:
Court Phone: (
)
Court Address:
Court Fax: (
)
Court Email:
Defendant Name:
A
Address:
Phone: (
)
City & State:
Date of Birth:
Ticket/Warrant #
Driver’s License #
Driver’s License State:
Convicted of (CDR Code-Description):
C
Date of Conviction:
Indictment #:
O
U
R
REFERRAL (Please check appropriate boxes)
T
Defendant is to enroll within 30 days, attend and complete a South Carolina certified ADSAP
(Alcohol Drug Safety Action Program) pursuant to SC Code of Law sections 56-5-2930, 56-5-2933 and
56-5-2990. Defendant is subject to contempt of this court if there is failure to enroll within 30 days.
Defendant is required to attend and complete a SC certified ADSAP and comply with recommendations
B
of ADSAP.
SC Department of Probation, Parole and Pardon Services (SCDPPPS) to receive notification if there
is failure to enroll, attend and complete a SC certified ADSAP and comply with recommendations of ADSAP
if the defendant is currently on supervision for the referred offense.
ADSAP Site:
Enroll by Date:
(See Site List)
Agency Name
Phone Number: (
)
Address:
ADSAP Fax: (
)
ADSAP Email:
U
S
NON-ADSAP ASSESSMENT/TREATMENT PROGRAM REFERRAL (See Site List.)
E
Program Site:
Reason for Referral:
Address:
C
City/State Zip:
Other Instructions:
Enroll by Date:
ADSAP/OTHER PROGRAM REPORT
Failed to Enroll
Treatment Recommendations:
Failed to Complete
PRI
Relapse Prevention
(Summary Attached)
P
Assessment Date:
Outpatient
R
Completion Date:
Intensive Outpatient
(
O
D
(for SCDPPPS)
Alternative Services)
G
Inpatient
R
Clinical Counselor (Signature)
A
M
Clinical Counselor Name (Print)
Date
Defendant’s Signature (If applicable)
Date
ADSAP COUNSELOR
U
The counselor’s signature indicates that treatment has been completed in accordance with South Carolina
S
law and that the defendant is in compliance with the recommendations of the ADSAP program and order of
E
E
the court.
Clinical Counselor Name (Signature)
Clinical Counselor Name (Print)
Date
Distribution: Original – Court; Copies – Defendant; ADSAP (and SCDPPPS if applicable)
ADSAP Form 101 02/2009

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