Drug Treatment and Impaired Driving Court Referral Form

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Please complete this initial referral to have a defendant considered for the Drug Treatment Court Program (DTC) or for the Impaired Driving Court Program (IDC).  All potential clients must:

  • Be residents of Dodge County
  • Have no current or prior prohibitive convictions
  • Must be at least 18 years of age
  • Must be assessed by the Treatment Court Staff.
    • DTC defendants must be facing charges stemming from a substance use disorder, including drugs and/or alcohol
    • IDC defendants must be facing either 3rd or 4th offense OWI or PAC charges

 

1

Date of Referral:

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Program:

Program:
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Client Name:

 *
4

Date of Birth:

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Gender:

Gender:
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Address:

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Phone Number:

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Email:

9

What is the best way for us to contact you?

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Referral Source:

Referral Source:
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Name:

 *
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Agency:

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Phone:

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Email:

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Date of Arrest: 

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Current Charges:

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Other Pending Charges:

18

Jurisdiction?

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