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