Certification and Program Forms

 

Starting a Program

There are approximately 55 Court Alcohol and Drug Programs within the state. A listing of these Programs is available from the Indiana Office of Court Services. These programs are governed by statute (IC 12-23-14) and by Court Alcohol and Drug Program Rules.

Certification

Court Alcohol and Drug Programs in Indiana are governed by statute (IC 12-23-14) and Judicial Conference Rules. Statutes and rules authorize the Indiana Office of Court Services to establish procedures to certify court alcohol and drug programs.

Client Demographics - Due March 31, 2018

Client Demographics Part 1 - This form is part 1 of 3 forms to enter the client demographic information for the 2017 reporting period.   Please note that in section 5 you will identify which charges your program served.  The felony and misdemeanor information should be entered in separate forms.  There is a separate link for the Felony Charges (Part 2) and Misdemeanor Charges (Part 3), if applicable.

Client Demographics Part 2 - This form is part 2 of 3 forms to enter the client demographic felony charge information for the 2017 reporting period.   Please enter your agency information and all applicable sections in this form.  There are separate forms for the Client Demographics that includes sections 2-4 and 6-11 of the report (Part 1) and the Misdemeanor Charges (Part 3-if applicable).

Client Demographics Part 3 - This form is part 3 of 3 forms to enter the client demographic information for the 2017 reporting period.   Please enter your agency information for Misdemeanor Charges (if applicable)  There will be a separate form for sections 2-5 and 6-11 in this report (Part 1) and the Felony Charges (Part 2).

Documents and Forms

Document/Form    
Staff Update Form    

 

Confidentiality Forms

Document/Form    
Sample Criminal Justice Consent for Release of Information Form Word PDF
Sample General Consent for Release of Information Form Word PDF
Sample Response to Subpoena - Criminal Word PDF
Sample Response to Subpoena - Civil Word PDF
Sample Qualified Service Organization Agreement Word PDF
Sample Prohibition on Re-Disclosure Word PDF

 

Sample Forms

Document/Form    
Orientation Form Word PDF
Client Rights Form Word PDF
Client Signature Page Word PDF
Assessment Form Word PDF
Individual Service Contract Sample 1 Word PDF
Individual Service Contract Sample 2 Word PDF
Sample Client Survey Word PDF
Sample Referral Agreement Word PDF