WALKE,R. COUI{TY ALABAMAVETE,RAIqS TRE,ATME,NT COURT

APPLICATIONAND

ORIENTATION HANDBOOK

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Full Name: Last:

Date ofBirth:

Race / Gender:

Attorney:

CaseNo(s).

Charge(s):

Physical Address:

City, Statg Zip

Telephone Number(s), including cell:

Email Address:

Mailing Address (if different):

City, State, Zip:

Employer:

Work Address:

City, State, Zip:

Work Telephone:

Local Relative (other than spouse):

Address:

City, State, Zip:

Telephone:

@ace) Gender)

First: MI

Iam: ()married ()divorced ()nevermarried ()widowed

Spouse's Name (if married):

Spouse's Address (if different):

City, State, Zip:

Spouse's Telephone:

Spouse's Employment:

Spouse's Work Telephone:

Children's names, ages,and where they reside:

List all past criminal convictions,date of convictioq and locationof conviction.

Are you currently on probationor parole from any past convictions? ( ) yes ( ) no

If on probatior/parole, name ofjurisdiction,name and telephone # of probation offrcer:

Do you currently have pending chargesin this or any other jurisdiction? ( ) yes ( ) no

Do you have reliable transportation? ( ) yes ( ) no

Do you have a Driver's License? ( ) yes ( ) no

DL No.

Do you have health insurance? ( ) yes ( ) no

ffyes, name of insurance provider:

Do you have a medical or mentalhealth diagnosis (to include PTSD,TBI, anxiety, depression, etc.)

Do you believe your diagnosis is ( ) yes ( ) noservice related?

Have you received any services at ( ) yes ( ) noa VA forthis diagnosis?

Do you believe you have asubstanceabuseproblem? ()yes ()no

If yes, what is your drug of choice?

Do you believe you need treatmentfor substance abuse or addiction? ( ) yes ( ) no

What talents or skills do you have?

What is the last grade of school completed?

Why are you applying forVeteran's Treatment Court?

What will prevent you fromcompleting Veteran's Treatment Court?

Explain, in detail, your actions thatled to these criminal charges. Use theback side ofthe page if needed:

Frequent Contacts

Drug Court Office-

Phone 205-384-7251

Fax 205-221-197 4

COLOR CODE: 522-L0Ll, MUST BE CALLED EVERYDAY BETWEENOSOOI{RS ANID 12OOI{RS

Address:

Walker County Dmg CourtP.O. Box 1385

Jasper, AL 35502

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ELIGIBILITY QIIES TIO}INAIRE

1) Eave you ever served in the U.S. Armed X'orces?o YesoNo

2) Eave you ever served in the U.S. National Guard or Reserves?o YesoNo

3) In what branch of theArmed F'orces did you serye?o Army (including Army National Guard or Reserve)o Nary (including Reserve)o Marine Corps (including Reserve)o Air f,'orce fncludingAirNational Guard and Reserve)o Coast Guard (including Reserve)o Other - Specify

4) When did you first enter the Armed Forces?o Montho Year

5) During this time where you assigned to a combat area?o YesoNo

6) When were you last discharged?o Montho Year

7) AJtogether, horv much time did you serye in the Armed Forces?o Number of Yearso Number of Monthso Number of Days

8) What type of discharge did you receive?o Honorableo General @onorable Conditions)o General (Without Honorable Conditions)o Other Than Honorableo Bad Conducto Dishonoratrleo Other - Specifyo Don't Know

9) Have you ever received sen'ices at any VA Hospital?o YesoNo

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RULES & REQIIIREMENTS

In orderto graduate from the Walker County Veterans Court, I will abide by all of thefollowing Rules and Requirements. I further understand that failure to comply withany such Rule or Requirement will result in a sanctioq which may includetermination from the Veterans Court Program and imposition of my jail or prisonsentence.

Initials Rule

I will attend every Court session as ordered, on time. I understandthat I am responsible for making sure that I have a reliable methodof getting to Court each week.

I will report as ordered by the court, Drug Court Coordinator,counselor and VA Representative.

I will comply with all terms of my Treatment Plan, and Iunderstand that it may be changed as needed during myparticipation in Veterans Court. I understand the extent andseriousness of my drug use or mental health issue may be assessedat different times during my participation in the Veterans CourtProgram and that I may be referred " to intensive outpatienttreatment, inpatient treatment, or other treatment programs deemedappropriate for me and that, if I am referred to such a program, Iwill be required to successfully complete the program before I cancomplete the Veterans Court Program. I understand that I may berequired to pay some or all of the costs of any treatment programto which I am referred.

I understand that I am responsible for calling the Color CodeSystem every day between 8am and noon at 522-t0ll. Iunderstand that a missed drug screerq abnormally diluted drugscreen, failure to provide a sample within 3 hours or a refusal tosubmit to a drug screen will be treated as a positive drug screen byVeterans Court and that I will be sanctioned by the Court. I alsounderstand that if I miss a drug screen, I should test as soon as Idiscover that I missed, and I should call my Veterans CourtCoordinator immediately to inform the Court of the missed screenand the makeup screen.

I will obtain and keep full-time employment or be enrolled as afull-time student unless on full disability or specifically excused

-_--ft o m-t'his-requirement_by-thee ou#

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I will not use or possess any mind-altering substance, includingalcohol, during my participation in the Veterans Court Program. Iunderstand I will be sanctioned for any use of mind-alteringsubstances, including alcohol, during my participation in theVeterans Court Program.NO SYNTHETICS oT ENERGY DRINKS.

I will not consume any prescription medication without firstobtaining a prescription from my doctor and having my doctor signan acknowledgement that I am participating in Veterans Court andpresenting the acknowledgement to Drug Court Coordinator, andreceivins permission from the Drue Court Coordinator to takethe medication. I understand that I am responsible for obtainingmy doctor's signature and any other necessary information(including diagnosis) on the Acknowledgement form, that I mayobtain these forms from the Veterans Court Officg and that I amresponsible for having such a form with me at all times in case I amrequired to seek immediate medical treatment. If I do not use thisform then I must set up an account with wrrvr,v.myireaith.rra.gori andallow Drug Courl Coordinator to print out my prescriptioninformation from the website prior to taking the medications I havebeen prescribed.

I will not consume any non-prescription medication without firstnotifying and obtaining the consent of the Drug Court Coordinator.Non-prescription medication includes, but is not limited to, dietpills, ephedra, cough medicine, cold medicine, and substancesintended to boost energy, including "stackers." I understand thatconsuming anv non-prescription medication whatsoeverwithout the prior notification to and consent of the VeteransCourt Supervisor. will cause me to be sanctioned bv the Court.

It is my responsibility to take the provided medical form with meand have the medical personnel complete the form at that time.This must be done on every visit to the Dr., Dentist, Therapist, ER,etc.

I will call my case manager immediately upon leavingDoctor/IVledical facility to inform them of the Dr. visit andmedications given.

I will bring the original completed medical form to my respectivecase manager within 2 business days. (i.e. if you go to the Dr. onSaturday, you must have the medical form tumed into the DrugCourt Coordinator on Monday or Tuesday if Monday is a holiday,of the next week)

thethe

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I understand I will take medications only as prescribed and that Iwill not take old medications that are not current (older than 30

days).

I understand that if I am taking an ongoing narcotic (i.e.

amphetamine for ADHD), then I must turn in a NEW medicalform EVERY time your medication is re-prescribed.

If Ordered by the Court, I may be required to obtain a Driver'sLicense if I do not currently possess one and I otherwise qualify.

If Ordered by the Court, I may be required to obtain a high-schooldiploma or GED Certificate.

I may not Dossess any weapons or firearms during myparticipation in Veterans Court.

I understand that any drug use within six (6) months of myanticipated Veterans Court graduation date may result in an

exlension of the time required to graduate from Veterans Court orexpulsion from the Program. I understand that I will not graduatefrom Veterans Court unless I have been drug free for a minimumof six (6) months.

I understand that I am responsible for keeping the Veterans CourtOffice informed at all times of my address, employment, and

telephone number. I understand that if the Veterans Court isunable to contact me because of inaccurate or outdated contactinformation, I will be sanctioned by the Court.

I understand that f may not be anyrvhere near anyone using.possessing. selling. manufacturing. or otherwise handling anvillegal substance.

I must not have any contact with any victims of or witnesses to thecrime/crimes which I have been charged with.

I must report to the Drug Court Coordinator any contact with lawenforcement, including any arrest, traffic violation, search, orquestioning. I must report such contact within one business day ofsuch contact.

I will not travel out of state without prior written authorizationfrom the Drug Court Coordinator.

I understand that I will be sanctioned for violation of any of theseRules & Requirements. I understand that my case will betreated individuallv and that anv sanctions I receive may bemore or less severe than sanctions given to other Participantswho violate the same or similar rules.

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I understand that my court fees will pay for all drug screens I musttake at the Walker County Community Corrections Lab during myparticipation in the Veterans Court Program.

I understand that I am required to pay Veterans Court fees of$45.00 per week while in Drug Court and all fees owed WalkerCounty must be paid before I will be allowed to graduate from theVeterans Court Program.

I will comply with all Court orders and requirements of the Court,the Veterans Court Coordinator, and Treatment Provider notspecifically set forth in these Rules & Requirements.

Participant Date

Witness Date

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I,IST OF SANCTTONSSanctions will be imposed for violation of any of the Veterans Court Rules &Requirements, as well as violation or any other failure to comply with an Order oftheVeterans Court Judgg the Veterans Court Coordinator, or the Treatment Provider.Sanctions will be imposed based on the specifics of the individual case. The sameviolation may not result in the same sanction for two different Veterans Courtparticipants. The following is a partial list of possible sanctions that may beimposed for non-compliance. The Court or Drug Court Coordinator may imposedifferent or additional sanctions that may be appropriate for the non-compliantconduct:

Court.

Release)

Community service

Electronic monitoring

Increase frequency of court appearances

Increase reporting to Case Supervisor

Increase frequency of drug screens

Delay in graduation date

Increase in costs to graduate from Veterans Court

Termination from the Veterans Court Program - Imposition of Prison or JailSentence

Additionally, I may be referred to and required to complete an outpatient or inpatientsubstance abuse treatment program or mental health program. Such a requirement isa therapeutic efflort to address my substance abuse problem or mental health problemand is not designed to be a sanction or punishment for any Rules or Requirements Imay have violated.

f have read and understand the sanctionr , Tln::ffitJo

for violation of the Veterans Court Rules &

- Panicipani

Witness

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Date

Urine Abstinence Testing and IncidentalAlcohol Exposure Contract

Recerrtadvancesintlrescienceofalcolroldetectioninurinelravegreaflyirrcreasedtlreabiiitytodetecteven@consumption. In addition, these tests are capable of detecthg alcohol ingestion for siqnificantlv longer neriods of time after a drinlcing episode.gecausJUresi tests are sensitive, in mre circumstances, exposure to non-beverage alcohol sources can result in detectible levels of alcohol (or itsbreakdotvn products). In order to preserve the integrity ofthe Veterans Court testing program, it has become necessary for us to reshict and/or

advise Veteraru Court participants regarding flre use ofcertain alcol'rol-containfurg products.

It is YOIIR responsibility to limit your exposure to the products and substances detailed belorv that contain ethyl alcohol. It is YOIIRresponsibility to read product labels, to knorv rvhat is contained in the products you use and consume and to stop and irspect these products

BEFORE you use them. Use of the products detailed belorv in violation of this contract rvill NOT be allorved as an excuse for a positive test

result When in doubt do not use. consume or aDDlv-

Coueh Svruos and Other Liquid Medications: Veterans Court participants are prohibited lrom using alcohol-containing cough/cold syrups, such as

Nyquil@. Other cough slrup brands and numerous other liquid medications, rely upon ethyl alcohol as a solvent. Veterans Court participants are

required to read product labels carefully to determine if flrey contain etlryl alcohol (ethanol).

Non-Alcoholic Beer and Wine: Althougfu legally considered non-alcoholic, NA beers (ex: O'Doul's@, Sharps@) do contain a residual amount ofalcohol that may result in a positive test result for alcohol, if consumed. Veterans Court participants are not permitted to ingest NA beer or NArvine.

Food and Other Ingestible Products: Numerous other consumable products contain ethyl alcohol flrat could result in a positive test for alcohol.

Flavoring exbacts, such as yalilln ey a.lmond extrac! and liquid herbal ex:tacts (such as Ginko Biloba), could result in a positive screen for alcohol

or its breakdorvn products. Conrmunion rvine, food cooked rvith rvine, and flamb6 dishes (alcohol poured over a food and ignited such as cherriesjubilee, baked Alaska) must be avoided.

Mouthrvash and Breath Strips: Most mouthrvashes (Listerine@, Cepacol@) and other breath cleansing products contain ethyl alcohol. The use ofmouflrrash containing eflryl alcoliol can produce a positive test result. Veterans Court participants are required to read product labels and educate

themselves as to rvheflrer a mouthu,ash product contains ethyl alcohol. Use of ethyl alcohol-containing mouthrvashes and breath ships by Veterans

Court participants is not permitted.

Hand Sanitizer: Hand sanitizers (ex Purell@, Germex@) and other antiseptic gels and foams used to disinfect hands contain up to 70% etltyl

alcohol. Excessive, ururecessary, or repeated use oftllese products could result in a positive urine test.

Hygiene Products: Aftershaves and colognes, hair sprays and mousse, astringents, insecticides @ug sprays such as OFF@) and some body lvashes

contain ethyl alcohol. While it is unlikely that limited use of these products rvould result in a positive test for alcohol (or its breakdoun products)

excessive, unnecessary, repeated use ofthese products could affect test results. Participants must use such products sparingly to avoid reaching

detection levels. Jusf as the court requires Veterans Court participants to regulate their fluid intatrie to avoid dilute urine samples, it is likewise

incumbent upon each participant to limit their use of topicatly applied (on the skin) products containing ethyl alcohol.

Solvents and Lacouers: Many solvents, lacquers, and surface preparation products used in the construction indust-y and at home contain ethyl

aicotrot. EoUr eicissive inhalation of vapors, and topical e:rposure to such products, can potentially cause a positive test result for alcohol. As lvithflre products noted above, Veterans Court participants must educate themselves as to the ingredients in the products they are using. A positive test

result rvill not be excused by reference to use ofan alcohol-based solvent

RXMEMBER! WHEN IN DOUBT. DO NOT USE, CONSI]ME. OR APPLY!

I have read and understand my responsibilities:

Participant's Signature

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Date

Participant Authorization for Disclosure of ProtectedIlealth lnformation

Participant Name: Case Number:

Date ofBirth:

I hereby authorize Walker County Veterans Court to disclose or obtain my health inforrnation as follows:

Disclose my health information to: Obtain my health information from:

Specific description of the health information to be disclosed/obtained:

The purpose for rvhich health information is to be disclosed/obtained:

By providing this Auflrorization, I understand the follorving:

1. I understand that this Authorization is voluntary. I may refuse to sign flris Auflrorization and myteatrnent and/or payment obligations rvill not be affected.

2. I understand &at I may revoke flris Authorization at any time by noti$ing Walker County Veterans

Court in rwiting, but if I do, it rvill not have any effect on disclosures prior to the receipt of flterevocation. It is understood that the duration of this consent 'rvill not be longer than rvould be

necessary and reasonable to carry out the purpose for which it is given.3. I understand that I will receive a copy of the Auflrorization form after I sign it.+. I understand that flris Auflrorization will expire on or termination of my case.

Date of E;rpiration5. I also give my permission to fa,x this information if necessary.

Participant's Initials

Signatrue of Participant or Participant's Representative

Printed Name of Participant Date

Signature of Witness Date

NOTE TO PARTY RDCDMNG INtrORLATION: This information has been ilisclosed to you from recorils whose confidentiality isprotccted by feileral lan, rvhich prohibits you from making any further disclosure ofinformation rrithout the specilic rvritten consent ofthe person to rvhom it pertains, or as other wise perrnitted by such regulation. A gener:rl release of medical or other information is not

utrPaEz

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Date

Medical FormName ofParticipant:

Date:

To Any Physician, Hospital, or other Medical or Health Care Provider:

I am currently a participant in the Walker County Veterans Court Program, in rvhich l amreceiving treatment for substance abuse or mental health issues. I am required to inform allmedial care providers of my participation in the Veterans Court Program and request tha! tottre extent possible, I request that I not be prescribed narcotic or other addictivemedications. Before I may accept a prescription from ybu for any medication, I must haveyou, as the treating physician, sign below that I have made you aware of my substance abusetreatrnent.

This form is also consent for release of information

Participant(Signature)

Current Prescription Dosage Quantity Refills Diagnosis

Treating Physician:

Treating Physician:

PrintName

Signature

Telephone #:

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Prescription Safe to Take ListThe following prescriptions are safe to take without priorauthorization if prescribed to you by a Doctor. You must stillcontact your Veterans Court Coordinator the next business dayand let them know that you have taken said medicine.

o Amoxicillin (Amoxil). Augmentino Bactrim. Cephalexin. Ciproo Clindamyeino Diflucan. Doxycycline. Flagylo Penicillino Steroid Packo Zithromax (Z-Pak)

By signing below, I attest that I understand that I am to contact myVeterans Court Coordinator the next business day.

Print Name:

Signature:

Date:

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TRAVELREQUEST

Date:

I, request approval to travel to

on(City, state).

Jhrough

Reason for

travel:

Participant

AnswerRequired to test the day before I leave on and the day

after my return on

Defendant required to call color daily and test at an approved facility when mycolor is called. Test must be faxed to 205-221-1974 by the facility performingthe test.

Defendant required to call Veterals Court Coordinator daily between 0800hrsand noorq Alabama time for instructions.

_ Approved

_ Denied

Veterans Court Coordinator

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Walker CountyCommunity Corrections

"Providing Altemathtes and Opportunity for firaker County Ci tizens "

Request to take previously prescribed medication

I, a Participant in the Walker County Veterans Court Program,hereby noti$r the Walker County Veterans Court Office that I was prescribed the medication listed belowbefore entering the Walker County Veterans Court Program and am requesting permission to continuetaking such prescription medication during my participation in the Walker County Veterans CourtProgram. I understand that a written decision on mv request will be provided to me" and that Icannot take such medication until I receive such written permission.

Medication Diagnosis Doctor Date Filled

I

2

J

4

5

6

Applicant

Applicant may take Medications numbered

Applicant may take Medications numbered but must terminate all use of suchmedication( )atleastno later than

months prior to Applicant's successful completion of the Program ( )

Applicant may take Medications numbered and may remain on suchmedications throughout participation in the Program.Applicant must comply with all policies and procedures regarding prescription medication and medforms. Failure to comply with such provisions may result in revocation ofthe authorization to takeprescription medication.

Drug Court Coordinator

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Walker CountyCommunify Corrections

" P rov i d i n g Al te nt a tiv e s a n d O pportun i ty fo r IYa lker C o u n ty Ci ti zen s "

CIIANGE OF ADDRESS, TELEPI{ONE OR BMPLOYMENT

Name ofParticipant:

Physical Address:

Mailing Address:

Telephone Number:

Cell Number:

Employer:

Employer Address:

Employer Telephone:

Supervisor:

Alternate Contact(s):

I understand that I am responsible for keeping the Veterans Court Office informed of a reliablemethod to contact me at all times. I understand that if the Veterans Court attempts to contactme and I do not respond within 24 hours that awarrant for my arrest may be issued.

***This form must be turned-in and approved by the Drug Court Coordinator before adefendant moves or changes a jobo**.

Participant Date

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DRESS CODE

When reporting for Veterans Court should be dressed accordingly. The following area few simple guidelines to use when deciding if something is appropriate to wear tocourt. If you should have any questions please speak to a member ofthe VeteransCourt team and they will provide you further instruction.

worn.

and/or stomach are not to be exposed or easily seen by others.

AII program participants are to stand at parade rest when standing before the benchduring Veteran's Court.

Please maintain appropriate hygiene. Be sensitive to the other individuals present inthe courtroom. Should these guidelines be violated you may be asked to cover theinappropriate article and/or be dismissed from court. Continued violations will bedealt with on an individual basis, and cause you to be sanctioned.

Thank you for your attention to this matter. Let's work together to make sure thisdoes not become a problem for you.

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Diluted Urine Sample

In urine drug/alcohol screening one of the most important things that must be done is tomake sure we receive a valid sample. One way this is done is by checking the sample for

dilution by measuring the creatinine level (Creatinine. is an amino acid contained inmuscle tissue and excreted in the urine at a steady rate.) The urine becomes diluted when

a person drinks large amounts of fluids, (water, any water based drink, tea, coffee,Gatorade, etc) or energy drinks such as Red Bull, Monster Fuel, 5 Eour Energy etc. Anormal urine sample will have a creatinine level of 2Omg/di or higher, a sample with avalue of less than 2Omg/dl will be considered dilute. When the urine is dilute, there is aIower concentration of drugs/metabolites and alcohol and testing may not detect them.

Because of this. the iudicial system considers a dilute sample a positive samrrle andsanctions may be imposed. Another reason dilute samples are considered positive is

because some people will drink large amounts of liquids in an effort to 'oflush" anythingfrom their system.

Some ways to avoid dilution are; plan the time you are going to leave your sample,about 2-2Yz hours prior to leaving the sample limit your fluid intake to 8 oz. every

40 minutes. Another way is to leave your sample early in the morning; urine isusually more concentrated early in the day, when you leave your sample look at it.If it appears light and you think it may be dilute, you can leave another sample,

but you must remain at the lab until you leave the next sample.

Lab staff members are not allowed to tell you whether your sample is dilute. Useyour o\iln judgment.

Signature:

Witness:

Date:

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Over the Counter (OTC) Safe Medication ListClassification Ingredient to Avoid OTC - Safe Medication

{llerry/Decongestant Brompheniramine, Chlorpheniramine,D exbromphenirarnine, Diphenhydramine,Acrivastinq Phenylephrine, PseudoephedringTriprolidine

Claritin*, Alavert* (Loratadine), Zyrtec*(Cetinzine), Clarinex@ @esloatadine), Allegra@(Fexofenadine), Tavist@ (Clemastine Fumarate)

Jough/Cold/Sore Tlroat Dexlrome&orplun (Guaifenesin) Mucinex@ Tablets, Robitussin@Plain, Cepastat", Chloraseptic@, Gly-Oxide@,Hall s@, Lozenges, Myci nette@, Nice@ Lozenges,Sucrets@ Lozenges, Vicks@ Cough Drops,Vicks@ Throat Discs, Vicks@ Vapor Rub

{DIID, Anorexiants,Itimulants, and Weigirt Control

Benzphetamine HCl, Sibutramine HCl,Diethylpropion HCl, Ephedrine, Ephedra,MaHuang, Methylphenidate, Modafinil, Pemoline,Phendimetrazine Tartrate

Weight Control- Diet Ayds@ (candy), Slim-trtint@ 1gum), Slim Fast@, Slender@ Xenical@(Orlistat)

A.nalgesics (pain reliefl Nonsteroidal Anti-Infl ammatorvAdvil@, A1eve@, Aspirin@, Bufferi;@, Tylenol@,Generics of any of these

tlasal Decongestant Sprays Oxlmetazline Tetrahydrozoline, Xylometazoline.Ephedrine,

L-Desoxyephedrile, Napluzoline, PhenyleplrineHCl, Propylhexedrine

Ocean*, gumistt, A1'r Saline@, NaSals,Salinex@

vloutllvashlDental Hygiene Alcohol Orajel', Perioseptic@, Crest Pro Healflr@Moufllvash

)iarrhea/Gas Diphenozylate HCl, Alcohol Kaopectate*, Kaopetolin@, Lactinex*, ImodiumA-D', Pepto Bismol@, Simedricone, Imodium@Multi Symtom

:{ausea (ArrtiemeEic/\ntivertgo Agents)

Buclizine HCl, Clclizine, Diphenlrydramine,Dimenhydrinate, Meclizine, ScopolamineTransdermal

Pepto Bismol@, Emefiol, Alka Seltzer@ Gold,Kaopectate@

iedatives/Anti -Arxiety/Sleep Doxylamine Succinate, Diphenhydramine Warm mil(, Melatonin

lrinary Tract lnfection AZO- Standard

leartburn/Indi gestion Kaopectate-, Pepto Bismol*, Alka Seltzer-Gold, Tums@, Pepcid@ Complete, Pepcid@ AC

opical Creams DipheniSdramine Ben Gay@, Icy Hot@, Anti-Itch creams, Anti-Fungal crearns, Calamine@ Lotion

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