Form Center • Chester County Drug Court Application

Chester County Drug Court Application

Steps

1. Step One This section is complete This section is incomplete
2. Offenses This section is complete This section is incomplete
3. Personal Information This section is complete This section is incomplete
4. Employment/School Information This section is complete This section is incomplete
5. Legal Information This section is complete This section is incomplete
6. Military Information This section is complete This section is incomplete
7. Substance Use Treatment This section is complete This section is incomplete
8. Mental Health History This section is complete This section is incomplete
9. Verification This section is complete This section is incomplete

Step One

Please review the Drug Court Brochure and the Drug Court Participant Handbook prior to completing the application
Drug Court Brochure
Drug Court Participant Handbook
Print Drug Court Application
If you are unable to submit the application online, you can print a copy and follow the instructions to submit using the link below.
Print Drug Court Application
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Offenses

The Chester County Drug Court Program is available to offenders who meet the following minimum requirements:
1. The client must be charged with a drug offense, a nonviolent offense, or a first offense DUI. A first offense DUI will also need to apply for ARD.
2. The client must have a substance use problem.
3. The client may have a prior criminal record, but may not have a record for a crime of violence (see list of Ineligible Offenses).
4. The client may not be currently on probation or parole.
5. The client must waive their right to a Preliminary Hearing and apply at the earliest opportunity.

The District Attorney’s Office retains full discretion in approving offenders for Drug Court.
OTN
Offenses Charged
OTN
Offenses Charged
OTN
Offenses Charged
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Personal Information

First Name
Last Name
Date of Birth
Date of Birth
Maiden Name (if applicable)
Social Security #
Address
City
State
Zip
Name of person with whom you live
What is their relationship to you?
Driver License/Photo ID State
Driver License/Photo ID Number
Previous Driver's License State
Previous Driver's License Number
Home Phone
Cell Phone
Email*
What is your highest level of education
Do you have health insurance?
Insurance Company
Policy Number
Upload a scanned copy of your insurance card.
Are you a citizen of the United States?
If you are not a US resident, what is your resident status?
If you are not a US Citizen, you must attach documentation of your residency status.
Do you require an interpreter?
If yes, what language?
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Employment/School Information

Are you currently employed?*
Type of Employment
Employer Name
Occupation
Are you currently a student?
Name of University/School
Student
Graduation Date
Graduation Date
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Legal Information

Are you represented by counsel?*
Attorney Name
Address
City
State
Zip
Phone Number
Email*
Are you currently in prison?
If yes, where?
Are there pending charges from other states against you? this includes other counties and/or states.
Describe charges
List all prior criminal history regardless of how the case was resolved, including juvenile, summary, and traffic offenses.
Date of Case
Date of Case
Location (County/State)
Describe charges and resolution of case
Date of Case
Date of Case
Location (County/State)
Describe charges and resolution of case
Date of Case
Date of Case
Location (County/State)
Describe charges and resolution of case
Date of Case
Date of Case
Location (County/State)
Describe charges and resolution of case
Date of Case
Date of Case
Location (County/State)
Describe charges and resolution of case
Are you on probation or parole?
If yes, where?
Probation Office Name
Probation Office Phone
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Military Information

Have you ever served in any branch of the military, including Reserves or National Guard?*
If yes, where?
What branch did you serve?
When did you serve?
Did you serve in combat?
If yes, where?
Are you eligible to receive VA benefits?
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Substance Use Treatment

Have you ever received substance use treatment?*
Name of provider/facility
Dates attended
Level of care
Did you successfully complete the program?
Name of provider/facility
Dates attended
Level of care
Did you successfully complete the program?
Name of provider/facility
Dates attended
Level of care
Did you successfully complete the program?
Are you currently taking medication to assist with your treatment?
Name of medication and dosage
Are you currently receiving substance use treatment?
If yes, where?
Name of prescribing physician or facility
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Mental Health History

Have you ever been diagnosed with a mental illness?*
If yes, diagnosis
Have you ever received mental health treatment?
Type of treatment, when and where
Are you currently prescribed medications for mental illness?
name of medication(s) and dosage
Name of prescribing physician/facility
Name of current mental health case manager
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Verification

I understand that I must complete this Drug Court Application truthfully, completely, and accurately to the best of my ability. I understand that my failure to do so will result in my Drug Court application being denied or my removal from the Drug Court Program.

I understand that I have a continuing obligation to report any contacts with the criminal justice system or the police that occur after the filing of my Drug Court application, and my failure to do so will result in my Drug Court application being denied or my removal from the Drug Court Program.

I hereby swear or affirm that I have reviewed the application and that each answer is true and accurate. I also swear and affirm that I have read and understand the Drug Court Brochure and Participant Handbook. I have reviewed this material and application with my attorney.

I understand and acknowledge that by filing this application, I am expressly waiving my right to a speedy trial and to be tried within the time limits set forth in the Pennsylvania Rule of Criminal Procedure 600. I hereby waive the following rights: (1) to have my case or cases tried within 365 days of the filing of the Complaint if I am at liberty on bail on such a case, and (2) to have my case or cases tried within 180 days of the filing of the Complaint if I am incarcerated on that case. I am specifically agreeing to extend the Rule 600 date in my case or cases by the period of time covered from the date this application is filed to the date upon which the Notice of Rejection is filed of record.

I understand that I will be required to admit to the factual basis supporting the charge(s) against me which may be used against me if I withdraw or am removed from the Drug Court Program.

Enter your full name as verification of this statement.*

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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Chester County Drug Court Application

Steps

Step One

Offenses

Personal Information

Employment/School Information

Legal Information

Military Information

Substance Use Treatment

Mental Health History

Verification

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