District Attorney Opioid Treatment Program Application

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? * Choose One Yes No

Have you previously been on Community Supervision? * Choose One Yes No

PERSONAL INFORMATION

Date of Birth *

Gender * Choose One Male Female

Race * Choose One American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race

Ethnicity * Choose One Hispanic or Latino Non Hispanic or Latino

Height *

Weight *

Eye Color * Choose One Black Blue Brown Green Gray

Hair Color * Choose One Bald Black Blonde or Strawberry Blonde Brown Gray or Partially Gray

Address *

Street or P.O. Box

City *

State * Texas Other State

Zip Code *

Email *

Cell Phone Number *

555-555-5555

Home Phone Number

555-555-5555

Drivers License Number *

Drivers License Issuing State * Texas Other 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: Spouse Parent Child Other Family Member Other Relationship to you:

First Name

Last Name

Relationship to you: Spouse Child Other Family Member Other Relationship to you:

First Name

Last Name

Relationship to you: Parent Spouse Child Other Family Member Other Relationship to you:

EDUCATION & EMPLOYMENT

Highest Degree or Level of School Completed * Choose One Some High School High School Graduate or Equivalent (GED) Some College or Technical School Associate's Degree (AA, AS) Bachelor's Degree (BA, BS) Master's Degree (MA, MS, MEng, MEd, MSW, MBA) Professional Degree beyond bachelor's degree (MD, DDS, DVM, LLB, JD) Doctorate Degree (PhD, EdD) Other Highest Degree or Level of School Completed

Are you a current student? *

Yes

No

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? * Choose One Pills Injections Other Pills and Injections 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

No

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

No

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. *

Drop a file here or click to upload Choose File

Maximum upload size: 516MB

Attach completed CSCD Forms: *

Drop a file here or click to upload Choose File

Maximum upload size: 516MB

Attach Release of Information Form *

Drop a file here or click to upload Choose File

Maximum upload size: 516MB

Attach Agreement

Drop a file here or click to upload Choose File

Maximum upload size: 516MB

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

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