Free Application/Referral For Specialty Court - Ohio

*Do not file with Clerk of Courts- file this application with the Specialty Courts Office, 3rd Floor, General Services Center, 315 High Street, Hamilton, OH 45011

REFERRAL TO SAMI COURT, DRUG COURT (C.D.A.T.), OR FELONY NON-SUPPORT DOCKET (FNS)
Defendant's Name: ___________________________________________ Date: _________________ Case # (`s): _________________________________,__________________________________________ Charges and Degree F/M (w/level):__________________________________________________________ Next Court Date: ____________________ Court/ Judge: _________________________________ DOB: __________________ SSN: ________________ Defendant's Attorney: _______________________ Defendant's Address (City / State): __________________________________________________________ Defendant's Phone #: _____________________________________________________________________ #1 Drug of Choice: ______________ How much/ how often: ___________ Date last used: ___________ #2 Drug of Choice: ______________ How much/ how often: ___________ Date last used: ___________ Current / Previous Drug and/or Alcohol treatment (i.e. inpatient, residential, outpatient, major withdrawal history, AA/NA involvement, etc.): ____________________________________________________________________________ CHECK WHICH COURT(S) APPLYING FOR: Drug Court Court of Original Jurisdiction: _______________________________________________________________ Arresting Officer: __________________________________________________________________________ Client's signature granting permission for the Adult Probation Department to begin a pre-sentence investigation to help determine the defendant's final eligibility for the C.D.A.T. program. It is understood that no questions will be asked by the Adult Probation Department concerning the charges in this case. ___________________________________ Defendant's Signature Date: ________________

SAMI Court Does the defendant have a mental health history including any of the following (circle all that apply): multiple hospitalizations, taking medications, guardianship, non-compliance with treatment, not taking medications, involuntary hospitalizations, community probate, suicide attempt(s)? Yes / No Mental Health Agency: __________________________ Psychiatrist: ___________________________ Mental Health Diagnosis: _______________________________________________________________ Felony Non-Support Court ­ Does the defendant have a current support order (not arrears only)? Yes / No Referral Source: ___________________________________