2. DUI Treatment Court Referral Form

   This form shall serve to provide a formal process for the submission of referrals who should be screened for possible entry into the DUI Treatment Court Program. The DUI Treatment Court program primarily considers repeat DUI offenses being handled in the State Court of Athens-Clarke County. However, the program will review each submission received for appropriateness. We will also strive to provide alternative possible options when a referral is not appropriate for our program.

   If you have any questions about this form or the information requested, please reach out to the DUI Treatment Court office at 706-613-3206. You may also reach out to the Coordinator, Nikita Robinson, directly at 762-400-6875 (calls only). Email is preferred for all non-urgent inquires (nikita.robinson@accgov.com); please copy the Case Manager, Grace Harten (Grace.Harten@accgov.com), on any email correspondence.

   Thank you for your interest in our program for your referral. Once we have received your submission and begin working on the screening process, we will keep you informed of our progress. The screening process can move fairly quickly at times and take several weeks to several months at other times; each referral and the surrounding circumstances are unique. If you want or need to follow-up with us at any point, please do. 

4. Please provide the first and last name of the person completing this form, relationship to the referred party, and the preferred method of contact*
6. Please provide the full legal name and birthdate of the person to be screened for the program*
8. Please provide the pending charges of the person being reffered and the county where they are pending*
10. Please provide the best contact number for the referral *

    This will be used to reach out to the referral to set up a screening appointment

11. Phone Type*
    -- Select One --HomeMobileWorkOther
13. Please provide the referral's email address if known
15. Please provide the first and last name of the parties handling the prosecution and defense of the referral's pending matters and their email addresses if known: These parties will receive notification of the referral submission and be kept up to date on the referral process.

    You do not need to re-record your information here if you are one of these parties and have indicated it above.

17. Please provide the referral's pending case number(s) if known
18. Please provide the date of the referral's next court appearance if known
    Please provide the date of the referral's next court appearance if known
20. Does the referral has any convictions of a violent or sexual nature? If so, please indicate what the charges were and when they occurred.
22. Please provide the referral's physical address where the referral will live if they are able to participate in the program.
24. Is the referral currently incarcerated? If so, please indicate where. *
26. If you are making this referral as a Clarke County prosecutor, does DUI Treatment Court have permission to view the pending matters via CASE? *

    1. Yes
    2. No
    3. N/A
28. If you are making this referral as a prosecutor outside of Clarke County,

    Please attach the referral's criminal history, driving history, and police reports associated with the referral's pending matters using the file "Add File(s)" button below. Alternatively, these documents can be emailed to nikita.robinson@accgov.com and grace.harten@accgov.com

30. .

    Add File(s)

32. If you have any other questions or comments you would like to submit with this referral, please provide it here
Leave This Blank:


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

    This field is not part of the form submission.

36. Submit

* indicates a required field