Free Summary of Substance Abuse Assessment Report - Michigan


File Size: 6.6 kB
Pages: 1
File Format: PDF
State: Michigan
Category: Court Forms - State
Word Count: 149 Words, 1,023 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://courts.michigan.gov/scao/courtforms/motorvehicleoffenses/mc212.pdf

Download Summary of Substance Abuse Assessment Report ( 6.6 kB)


Preview Summary of Substance Abuse Assessment Report
Approved, SCAO

Original - Court 1st copy - Agent

STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT
Court address

CASE NO. SUMMARY OF SUBSTANCE ABUSE ASSESSMENT REPORT
Court telephone no.

1. The defendant,
Name

: .
Date

a. was evaluated by this agency on b. failed to report for evaluation. 2. This agency recommends that the defendant: a. will not benefit from substance abuse service.

b. will benefit from the services specified below. Participation should continue for
Period of time

.

Alcohol Highway Safety Education (AHSE) Treatment services: 3. Comments: outpatient inpatient residential mental health

4. Suggested providers:
To be completed on direction of court.

TYPE OF SERVICE AHSE, Outpatient, Inpatient, Residential or Mental Health

AREA AGENCY(IES) PROVIDING SERVICE Name, address, and telephone number

CONFIDENTIAL INFORMATION - NOT TO BE KEPT IN LEGAL CASE FILE

Agency Address City, state, zip MC 212 (6/99) Telephone no.

Signature Title Date

SUMMARY OF SUBSTANCE ABUSE ASSESSMENT REPORT