Approved,  SCAO

STATE OF MICHIGAN

Original - Court
1st  copy  -  Agency

2nd  copy  -  Probation  officer
3rd  copy  -  Defendant

CASE NO.

JUDICIAL DISTRICT
JUDICIAL CIRCUIT

ORDER FOR
SUBSTANCE ABUSE EVALUATION

Court  address

Court  telephone  no.

THE PEOPLE OF

The State of Michigan

Defendant's name, address, and telephone no.

v

The defendant in this case was convicted of an alcohol/controlled substance offense.

, the defendant's breath-alcohol content  was

    .

1. The defendant, at his/her own cost, shall have a substance abuse screening and assessment by

On the date of the arrest,

Date

IT IS ORDERED:

Agency  name  and  address

by

Date

.

to determine whether the defendant will benefit from rehabilitative services.  The agency shall submit a written report to the court

2. If the defendant is on bond, he/she shall report to the named agency for evaluation by

    .

Date

If the defendant fails to report by the above date for evaluation, the court may issue a bench warrant for his/her arrest.

3. Failure to appear for the evaluation may result in sentencing without the benefit of the evaluation.

4. If the defendant is in jail, the evaluation shall be performed either at the jail or at the named agency.

Date

Judge/Magistrate

I acknowledge that I have received a copy of this order for evaluation on

ACKNOWLEDGMENT OF SERVICE

Date

Defendant

NOTICE OF MAILING BY COURT

A copy of this order was mailed to/personally served on the named agency on

Date

Date

Signature and title

.

.

MC 211   (3/08)   ORDER FOR SUBSTANCE ABUSE EVALUATION

MCL 257.624a(3), MCL 257.624b(1), MCL 257.625b(5),
MCL 333.7408a(3), MCL 436.1703(1)(a)