District Attorney Opioid Treatment Program Application

CASE INFORMATION

Case Number

(001-80000-2017)

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First Name *

Middle Name

Last Name *

List all prior names, maiden name, former or current aliases, etc. *

N/A if Not Applicable

Defense Attorney First Name *

Defense Attorney Last Name

Defense Attorney Phone Number *

(555) 555-5555

Defense Attorney Email Address *

Are you currently on Community Supervision? *

Have you previously been on Community Supervision? *

PERSONAL INFORMATION

Date of Birth *

Gender *

Race * Race

Ethnicity *

Height *

Weight *

Eye Color *

Hair Color *

Address *

Street or P.O. Box

City *

State * State

Zip Code *

Email *

Cell Phone Number *

555-555-5555

Home Phone Number

555-555-5555

Drivers License Number *

Drivers License Issuing State * Drivers License Issuing State

Names of people who stay or live in your home and their relationship to you: *

First Name

Last Name

Relationship to you: Relationship to you:

First Name

Last Name

Relationship to you: Relationship to you:

First Name

Last Name

Relationship to you: Relationship to you:

EDUCATION & EMPLOYMENT

Highest Degree or Level of School Completed * Highest Degree or Level of School Completed

Are you a current student? *

Yes

If yes, what school/university do you attend?

What is your current grade/level?

Current Employer *

Supervisor First Name

Supervisor Last Name

Job Title *

Annual Income *

Employer Address *

(Street number, city and state)

Employer Phone Number *

(555-555-5555)

OPIOID USE

How do you consume opioids? * How do you consume opioids?

How frequent is your opioid use? *

When was your last use of any opioid? *

POLICE CONTACT: List all incidents in which you were cited, arrested, accused or charged with a crime other than a traffic violation. Include incidents that were set aside, referred to pre-trial diversion or pardoned. (Provide full explanation including incident date, location, police agency and disposition or court action)

Juvenile Police Contact *

Adult Police Contact *

Have you EVER had pre-trial diversion intervention, granted deferred adjudication, probation or have been convicted for any offense other than a Class C misdemeanor? *

Yes

If yes, please provide details: *

Other than your arrest for this offense, have you ever been placed in a city or county jail before? *

Yes

If yes, please provide details:

Please review your answers carefully and read the following statement before submitting this application!

CERTIFICATION: I hereby certify that there are no willful misrepresentations, omissions, or falsifications in the foregoing statements and answers to questions. I understand that any omission or false statements on this application shall be sufficient cause for denial of admittance into the Collin County Criminal District Attorney's Opioid Treatment Program.

Signature *

Clear

Attach Notarized Sworn Statement as described in Section 8 of Program Guidelines. Statement must be typed, signed, sworn, notarized and describe facts and circumstance of the offense for which the offender has been arrested/charged. *

Maximum file size: 516MB

Attach completed CSCD Forms: *

Maximum file size: 516MB

Attach Release of Information Form *

Maximum file size: 516MB

Attach Agreement

Maximum file size: 516MB

Upon successful completion, the defense attorney will receive an email confirmation.

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District Attorney Opioid Treatment Program Application

CASE INFORMATION

PERSONAL INFORMATION

EDUCATION & EMPLOYMENT

OPIOID USE

Please review your answers carefully and read the following statement before submitting this application!

Upon successful completion, the defense attorney will receive an email confirmation.

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District Attorney Opioid Treatment Program Application

CASE INFORMATION

PERSONAL INFORMATION

EDUCATION & EMPLOYMENT

OPIOID USE

Please review your answers carefully and read the following statement before submitting this application!

Upon successful completion, the defense attorney will receive an email confirmation.

Latest News

Daily Docket/Case Search

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Social Media Terms of Use