DUI Court Application

DUI Court Application

PLEASE NOTE: DUI PRESCREENINGS WILL TAKE PLACE ON MONDAY through FRIDAY MORNINGS FROM 9-NOON ONLY.

Date of Application: ______City of Residence: ______

Name of Applicant: ______Age or DOB: ______

Case #(s): ______

Attorney Name: ______Attorney Phone #: ______

Case info (please circle answer):

o  2nd DUI w/prior within a year

o  2nd DUI w/BAC of .20 or higher

o  3rd DUI

Attorney Pre-screening questions:

(note: an answer other than “yes” may mean the applicant is not appropriate for the program).

1.  Does the applicant live within the geographic boundaries of the program (HJC or WJC areas)? [ ] yes [ ] no

2.  Does the applicant have arrests or convictions for drug sales, violence or gang activity? [ ] yes [ ] no

3.  Can the applicant and his/her roommate(s) comply with an alcohol ban? [ ] yes [ ] no

4.  Is the applicant’s employment consistent with the demands of the program (appearing in court, probation supervision, treatment and testing)? [ ] yes [ ] no

5.  Is the applicant familiar with the program and its activities (duicourt.occourts.org)? [ ] yes [ ] no

6.  Does the applicant have a transportation plan which will allow him/her to appear at all activities (without driving in violation of their license suspension or revocation)? [ ] yes [ ] no

7.  Does the applicant believe that he/she has a substance abuse problem and wants to participate in treatment for the problem? [ ] yes [ ] no

8.  I have screened the applicant and believe the applicant has no medical or mental health issues that would prevent regular and successful participation in the program. (If the applicant is under a doctor’s care for a chronic health issue or mental health treatment a doctor’s letter explaining the issue, the treatment proposed and necessary medications will be helpful). [ ] yes [ ] no

9.  I have screened the applicant and believe the applicant does not take (or need to take) any medications which are disallowed by the program? [ ] yes[ ] no

______

Attorney signature Date

Evaluation Dates/times/locations:

Probation: Date: ___/___/___ Time: ______Location: Court H10

HCA: Date: ___/___/___ Time: ______Location: HCA Office