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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