*Do not file with Clerk of Courts- submit this application to the Specialty Courts Office, 3rd Floor, Government Services Center, 315 High Street, Hamilton, OH 45011 APPLICATION TO SAMI COURT, DRUG COURT (CDAT), OR VETERANS TREATMENT COURT (VTC) Offender's Name: __________________________________ Date: ______________________________________ Case # (s): ___________________________, _____________________________, __________________________ Charges and Degree F/M (w/level):_____________________________ Next Court Date: _____________________ Trial Court Judge: _____________________ DOB: ______________ SSN: ________________________________ Defense Attorney: _____________________________ Offender's Phone #: ________________________________ Offender's Address (City/State): ___________________________________________________________________ Current/Previous Drug and/or Alcohol Treatment (i.e. inpatient, residential, outpatient, etc.): ___________________ __________________________________________________________________________________________________ CHECK WHICH COURT(S) APPLYING FOR: Drug Court: If the offender has filed a Motion for Intervention in Lieu of Conviction with the Butler County Clerk of Courts, in order for a pre-sentence investigation and substance abuse assessment to be completed, a signature by the Trial Court Judge is needed to acknowledge that he/she has been informed of said motion; and that the offender is to be assessed for the Butler County CDAT Program. Trial Judge Signature_____________________________ Date: ______________________________________ The offender's signature is also needed to grant permission for the Adult Probation Department to begin a presentence investigation to help determine the offender's final eligibility for the Butler County CDAT Program. Offender's Signature _____________________________Date: ______________________________________ SAMI Court: Does the offender 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: ____________________________________________________________________ Veterans Treatment Court: Does the offender have a mental health and/or substance abuse history including any of the following (circle all that apply): multiple hospitalizations, taking medications, guardianship, noncompliance with treatment, not taking medications, involuntary hospitalizations, community probate, suicide attempt(s)? Yes / No Branch of Service: _______________ Mental Health Diagnosis (if applicable): __________________________ If the offender has filed a Motion for Intervention in Lieu of Conviction with the Butler County Clerk of Courts, in order for a pre-sentence investigation and a Veterans Treatment Court assessment to be completed, a signature by the Trial Court Judge is needed to acknowledge that he/she has been informed of said motion; and that the offender is to be assessed for the Butler County Veterans Treatment Court Program. Trial Judge Signature_____________________________ Date: ______________________________________ The offender's signature is also needed to grant permission for the Adult Probation Department to begin a presentence investigation to help determine the offender's final eligibility for the Butler County VTC Program. Offender's Signature ____________________________ Date: ______________________________________ Referral Source Signature: ____________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com