Application For Supervised Diversionary Program {JD-CR-154}

APPLICATION FOR SUPERVISED DIVERSIONARY PROGRAM JD-CR-154 Rev. 7-16 C.G.S. § 54-56l; P.A. 16-167 § 46 STATE OF CONNECTICUT SUPERIOR COURT JUDICIAL BRANCH www.jud.ct.gov Instructions to defendant: 1. Fill out the Application and Military Status sections and sign this form. 2. Give the original to the clerk of the court. 3. Send a copy to the prosecuting attorney (the State's Attorney) for your case. 4. Keep a copy for your records. Notice to Clerk: Seal file on order of the court per C.G.S. § 54-56l(c). The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. ADA Notice TO: The Superior Court of the State of Connecticut GA/JD number Address of court Docket number Address of defendant (Number, street, apartment number, town, and zip code) Telephone number of defendant CMIS case number Name of defendant Alias/Maiden name of defendant Offense(s) charged Application I am charged with the offense(s) listed above, which are crime(s) or motor vehicle violation(s) that are not serious in nature, but could result in a jail sentence. ("X" all that apply.) I have a psychiatric disability and my mental or emotional condition is not caused only by substance abuse. Without care and treatment, my mental or emotional condition has substantial adverse effects on (strongly interferes with) my ability to function. I am a veteran and I have a mental health condition that is amenable to treatment (can be treated). I have been discharged or released under conditions other than dishonorable from active service in the armed forces as defined in section 27-103 of the Connecticut General Statutes. I am applying for the Supervised Diversionary Program. If my application is granted, and I am allowed into the program, I agree to the following: 1. To give the state more time to prosecute me (the tolling of the statute of limitations and the waiver of the right to a speedy trial) for the offense(s) listed above if I do not successfully finish the Supervised Diversionary Program. 2. To any condition(s) that may be required by the Court Support Services Division (CSSD) about my taking part in the Supervised Diversionary Program, including conditions about my taking part in meetings, treatment, or sessions of the Program. I also understand that I cannot take part in the Supervised Diversionary Program if: 1. I am not eligible for the Accelerated Pretrial Rehabilitation Program under section 54-56e (c) of the Connecticut General Statutes, unless I am not eligible for that Program because I am eligible for the Family Violence Education Program under section 46b-38c instead, and the court finds that the Supervised Diversionary Program is better for me than the Family Violence Education Program under the circumstances of my case. 2. I have used the Supervised Diversionary Program twice before. I also understand that: 1. The court will send notice (tell) any victim of the offense(s) listed above that I have applied for the Supervised Diversionary Program, and that the victim can tell the court whether he or she thinks I should be allowed to take part in this Program. 2. CSSD will confirm my eligibility for this program, get an assessment of my mental health condition, and find out if the right supervision, treatment, and services options are available for me. If so, CSSD will make a treatment plan for me, and give that treatment plan to the court. 3. If my application is granted, and I am allowed into the Supervised Diversionary Program, the court will refer me to CSSD, which may work with the Department of Mental Health and Addiction Services, the Connecticut Department of Veterans Affairs, or the United States Department of Veterans Affairs, where appropriate, to give me the right supervision, treatment, and services. A probation officer who has a reduced (smaller) caseload and specialized training in working with people who have psychiatric disabilities will supervise me. 4. Information about me and why I took part in the Supervised Diversionary Program will be available to State and local police officers for five years after I am allowed into the Program, even though the charge(s) for the offense(s) listed above will be dismissed if I successfully complete the Program. 5. Details of my mental or emotional condition or substance abuse issues may be made known to the court, and may become part of my court file. I give my permission to CSSD to get information about whether I have used the Supervised Diversionary Program before and whether I am eligible for the Accelerated Pretrial Rehabilitation Program. Continued on next page... Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Military Status Have you ever served in the U.S. Armed Forces, including the Connecticut National Guard Yes No (as defined in section 27-103 of the Connecticut General Statutes)? If you have ever served in the armed forces: ("X" one) I am an active member of the armed forces. I was discharged or released from active service in the armed forces honorably or under conditions other than dishonorable. I was dishonorably discharged from active service in the armed forces. By signing this form, I am saying that I understand all of the information included on this form, and I request that I be allowed into the Supervised Diversionary Program under section 54-56l of the Connecticut General Statutes. I have read the above information and understand it. Signed (Duly authorized person) Signed (Defendant) Print name Date signed Consented to by (Parent or Guardian) Date signed Oath The defendant stated under penalties of perjury before me, duly designated by the clerk and authorized to administer oaths, that (s)he has not previously participated in the Supervised Diversionary Program established under section 54-56l of the Connecticut General Statutes more than once. Signed (Assistant Clerk/Duly authorized person) Print name Date signed First Order of the Court ("X" all that apply) (If the application is denied and the file ordered unsealed, consider ordering the defendant's telephone number redacted.) The application is denied. The defendant's oath under section 54-56l(c) of the Connecticut General Statutes was taken: in open court outside of court by a person designated by the clerk and duly authorized to administer oaths The application is granted. The c