COLORADO

Department of Corrections

Division of Adult Park

Revised January 2019

Interstate Compact Unit

940 N Broadway

Deliver, CO 80203

P 303.763.2408 F 303.861.1548

DOC interstatetreatment.state.co.us

OUT-OF-STATE OFFENDER

CLIENT QUESTIONNAIRE

The following questions must be answered by all clients seeking admission to this program for any education or treatment; as required by Colorado law. Refusal to cooperate, or failure to provide complete or accurate information, including failure to sign a release of information to the referring criminal justice agency, will result in a denial to attend the treatment program and notification of authorities, in accord with the requirements in C.R.S. 17-27.1-101.

1) Are you required to report your treatment progress or completion to any Court, Department of Corrections, Parole, Probation, Adult Diversion Program, or DMV?

Yes

2) Do you have any pending cases, Probation/Parole supervision, or warrants in any other state?

Yes

If yes to 1 or 2, please answer the following questions:

3) In what state was the Crime committed?

4) Who are you to report the treatment to? (Example: Court, Judge, Probation Parole, etc.)

5) Are you, or will you be under the supervision of a Probation or Parole Officer in Colorado?

Yes

6) For DUI Offenders only: Are you seeking education or treatment for the sole purpose of restoring you driving privileges as the result of an alcohol or drug related driving Offense in another state, but are not under court order to do so?

Yes

Your Name:

Date of Birth:

Social Security Number:

Place of Birth:

Signature:

Today's Date:

If you answered "Yes" to 1 or 2 above, please provide the following:

Name, address and phone number of your Probation officer, parole officer, judge Or diversion officer.

A copy of your probation, parole, court or diversion order, including treatment requirements must be included.

Form C

Jared Polis , Governor : Dean Williams , Executive Director

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