CN-500 ANCH (/1)(cs) CINA THERAPEUTIC COURT PARICIPANT ACKNOWLEDGMENT OF PROGRAM REQUIREMENTS IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT ANCHORAGE In the Matter of: ) ) ) ) ) ) ) ) CASE NO(s). ) Participant(s) Name(s): Please initial each statement to acknowledge that you understand and agree to the program requirements of CINA Therapeutic Court (CTC): 2. I will abstain from alcohol, all illegal substances, and other intoxicants. 3. I will attend, participate in, and complete treatment, therapy, educational programs, and court ordered services. 4. I will appear come to court due to illness or another emergency, I will notify my attorney no later than the morning of the court date. 5. I understand my case will be discussed by all members of the CTC team including the judge. families. This information is not to be discussed with non-CTC members. 7. I will be drug and/or alcohol tested on a frequent basis and submit to drug and/or alcohol testing including urine analysis (UA) and breath testing as treatment provider, OCS, and the court and provide verification of a A Page 2 of 2 CN-500 ANCH (6/18)(cs) CINA THERAPEUTIC COURT PARICIPANT ACKNOWLEDGMENT OF PROGRAM REQUIREMENTS 9. I understand CTC provides positive rewards for success in this program. 10. I understand that I can be sanctioned for non-compliance with my treatment plan, the court's requirements or any court order. 11. I will sign all releases of confidentiality necessary for the court, including releases that allow access to my assessment, treatment information, medical, mental health, and behavioral health records. I understand the court will also issue an order allowing for the exchange of information between the treatment provider and the CTC Team members. I have read this document and have reviewed it with my attorney. I understand and agree to abide by the above terms of the CTC Program. Participant Signature Date I certify that on a copy of this document was emailed/hand-delivered to: AG PD OCS Tribe GAL OPA-AJR OPA-ASD OPA-CLS Clerk: American LegalNet, Inc. www.FormsWorkFlow.com