EXAMINATION FOR ALCOHOL OR DRUG DEPENDENCE MOTION AND ORDER STATE OF CONNECTICUT SUPERIOR COURT JD-CR-91 Rev. 5-15 C.G.S. § 17a-693, 17a-694, 17a-695, 17a-696, 17a-699 Instructions To Defendant - Fill out this form and give it and 2 copies of it to the Clerk of Court and give another copy to the Prosecuting attorney(s). To Clerk - If motion is granted, immediately distribute copies of this form and the defendant's Consent for Release of Information as follows: (1) Send to CSSD - copy of this form and copy of consent. (2) Send to DMHAS treatment facility - copy of this form and original signed consent. (3) Keep the original of this form and copy of consent in court file. The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www. jud.ct.gov/ADA. Next court date Docket number ADA NOTICE TO: The Superior Court of the State of Connecticut Judicial District or Geographic area Name of defendant Defendant's telephone Date of birth Address of court Sex Race Motion (To Be Completed by the Defendant or State's Attorney) Address of defendant Name and address of defendant's attorney Crime(s) charged/convicted of (Include date offense committed) If incarcerated, location being held at (name and address of facility) Released Incarcerated State's Attorney I, the Defendant ask for an order of the court that the defendant be examined pursuant to section 17a-694 of the General Statutes to determine if the defendant is dependent on drugs or alcohol. I make the following statements: Defendant charged but has not had a trial yet Defendant convicted but not yet sentenced Is not charged with 1. The defendant Seeks waiver of ineligibility because of being 1. The defendant was not convicted of murder, charged with attempt to commit murder, kidnapping, a violation of sections 14-227a or 53a-60d of the Connecticut General robbery in the first degree, or any felony Statutes, or with a class A, B, or C felony. involving serious physical injury. 2. The defendant Was not twice previously ordered treated 2. The defendant has not been previously Seeks waiver of ineligibility because the ordered treated under sections 17a-699 or defendant was twice previously ordered treated 19a-387 of the Connecticut General Statutes or section 21a-285 of the Connecticut General under sections 17a-696, 17-155y (i), or 19a-386 of the Connecticut General Statutes, or under section 21a-284 of the Connecticut General Statutes, revised to 1989. Statutes, revised to 1989, or any combination of these sections. I have read the above information. I understand it, and I agree with it. Consented to by (Parent or Guardian) Signed (Defendant) Signed (Attorney for Defendant) Signed (State's Attorney) Date signed Order The foregoing motion is denied. Having found that the interests of justice will be served, the foregoing motion is granted, subject to the defendant executing the attached Consent for Release of Information. By the court (Print or type name of Judge) Signed (Judge or Assistant Clerk) Date signed Appointment Of Examiner(s) TO: The Clinical Examiner You are ordered to examine the above-named defendant, prepare a signed written report of your findings, and deliver it to the court, the Court Support Services Division, the state's attorney and the defendant's attorney within thirty days of the Date of Order shown below. You will not be required to be present to testify on the report unless you receive a separate notice from the court, the state's attorney or the defendant's attorney requesting your presence to testify. In your report, you shall indicate whether the defendant was an alcohol-dependent or drug-dependent person at the time of the crime(s). If you determine that the defendant was dependent on alcohol or drugs, you are further ordered to determine (1) the history and pattern of the dependency, and (2) whether the defendant presently needs and is likely to benefit from treatment for the dependency. If you determine that the defendant presently needs and is likely to benefit from treatment, you shall recommend treatment, including provisions for the appropriate placement and the type and length of treatment, which may include provisions for outpatient treatment, and state the date that space will be available in an appropriate treatment program, provided such date shall not be more than forty-five days from the date of the examination report. Date of Order By the court (Print or type name of Judge) Signed (Assistant Clerk) Date signed Notice To Defendant - Nothing that you say during this examination, if the judge orders it, may be used to show that you are guilty in your criminal case. American LegalNet, Inc. www.FormsWorkFlow.com