ADSAC

Name

First NameLast Name

Date of Birth

Date

Social Security Number

Address

City

State

Zip

Phone Number

Email*

example@example.com

Occupation

Race

Education Level

Marital Status

Drivers License Number

State

Sex

Date of Arrestor Incident

Date

County Arrested In

Location and city of last substance use or before arrest (bar/club name/friend's house/home):

Name of Probation Officer or Caseworker

Probation Officer or Case Worker Phone Number

Name of Attorney

Attorney Phone Number

Arresting Authority

My signature indicates that the above information is truthful to the best of my knowledge. Any falsifications will result in withholding of certificates and/or verifications. I have a received a copy of TVC Handbook, which outlines Client grievance process, confidentiality, and rights.

Signature*

Date

Financial and Attendance Policy

Please initial next to each statement below acknowledging you have read, understand, and agree to all requirements.

I understand that I am required to pay a non-refundable deposit of $100 to schedule my ADSAC assessment but I can pay the full amount of my ADSAC assessment at the time the appointment is made. The remaining balance is due on or before the ADSAC appointment.*

I understand that I lose my $100 deposit for any of the following reasons: - If I do not pay my remaining balances on or before the ADSAC appointment. - If I do not show up for my appointment. - If I do not call at least 24 hours in advance to reschedule my appointment. - If I reschedule my appointment more than one time. - If I am 15 minutes or more late to my appointment.*

I understand by scheduling and paying my deposit I am agreeing to attend my scheduled ADSAC assessment.*

I understand if I need to reschedule my ADSAC assessment, I must call at least 24 hours in advance*

I understand the ADSAC assessment will last 2- 3 hours*

I understand I may only reschedule my ADSAC assessment one time*

Please remember you must pay your remaining balance on or before your scheduled ADSAC appointment. If you do not pay your balance on or before your scheduled ADSAC assessment you will lose your deposit. The full amount is due in order to schedule a Saturday appointment. All payments must be paid by cash, money order or credit card.

Client Signature*

Date*

Date