ADSAP/EDUCATION/TREATMENT REFERRAL FORM

ENROLLMENT REQUIRED WITHIN 30 DAYS

Court:	City/County:
Referring Judge Name:	Court Phone:
Court Address:
Court Fax:	Court Email:
Defendant Name:
Address:	Phone:
City & State:	Date of Birth:
Ticket/Warrant #	DL#	DL State:

Convicted of:	DUAC: 1st Offense	DUI: 1st Offense
DUAC: 2nd Offense	DUI: 2nd Offense
DUAC: 3rd Offense	DUI: 3rd Offense
DUAC: 4th Offense	DUI: 4th Offense or Subsequent
Date of Conviction:	Indictment #
REFERRAL (Please check appropriate boxes)

Defendant is to enroll within 30 days, attend and complete a South Carolina certified ADSAP

(Alcohol Drug Safety Action Program) pursuant to SC Code of Law sections 56-5-2930, 56-5-2933 and

56-5-2990. Defendant is subject to contempt of this court if there is failure to enroll within 30 days.

Defendant is required to attend and complete a SC certified ADSAP and comply with recommendations

of ADSAP.

SC Department of Probation, Parole and Pardon Services (SCDPPPS) to receive notification if there is

failure to enroll, attend and complete a SC certified ADSAP and comply with recommendations of ADSAP

if the defendant is currently on supervision for the referred offense.

ADSAP Site (See Site List.):	Enroll By Date:
Agency Name:	Phone Number:
Address:
ADSAP Fax:	ADSAP Email:

NON-ADSAP ASSESSMENT/TREATMENT PROGRAM REFERRAL (See site list.)

Program Site: Reason for Referral:

Address:

City/State Zip:

Other Instructions:

Enroll by Date:

ADSAP/OTHER PROGRAM REPORT

Failed to Enroll	Treatment Recommendations:

Failed to Complete (Summary Attached)	PRI	Relapse Prevention

Assessment Date:	Outpatient

Completion Date:	(for SCDPPPS)	Intensive Outpatient (Alternative Services)

Inpatient

Clinical Counselor (Signature)

Clinical Counselor Name (Print)	Date	Defendant’s Signature (If applicable) Date

ADSAP COUNSELOR

The counselor’s signature indicates that treatment has been completed in accordance with South Carolina

law and that the defendant is in compliance with the recommendations of the ADSAP program and order of

the court.

Clinical Counselor Name (Signature)

Clinical Counselor Name (Print)	Date

Distribution: Original – Court; Copies – Defendant; ADSAP (and SCDPPPS if applicable)	ADSAP Form 102 02/2009

NON CMS

D

E

COURT

USE

PROGRAM

USE

A

B

C

ADSAP/EDUCATION/TREATMENT REFERRAL FORM

MCritchley

2009-02-06

Winkie Clark

LRADAC