APPLICATION TO ADMISSION: PHASE ADVANCEMENT TRACKING SHEET

Judicial Circuit

Palm Beach County Drug Court Office

3228 Gun Club Road, Rm. B-126

West Palm Beach, FL 33406

The following form must be completed by the participant prior to
admission to the Drug Court Program. It is the sole responsibility of
the participant to complete and return this form. Failure to provide
this form will result in postponement of admission until the completed
form is presented.

Applicant's Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date of Application:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Applicant's Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Witness Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

To be admitted into the Drug Court Program you must have attended a
minimum of four (4) community 12-Step (NA/AA) meetings prior to your
Treatment Recommendation Hearing. You must attach an original *Proof of
Attendance Form* to this Phase Advancement Tracking Sheet, verifying
that you have met this qualification, in order to become a participant
in Drug Court.

For Office Use Only

Drug Court I.D.#: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Case #:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

PHASE I TO PHASE II: PHASE ADVANCEMENT TRACKING SHEET

The following form must be completed by the participant prior to
advancement from Phase One (I) to Phase Two (II). It is the sole
responsibility of the participant to complete and return this form.
Failure to provide this form will result in postponement of advancement
until the completed form is presented. The participant must also be
current with all other program requirements to be considered for phase
advancement.

Participant Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date of
Admission: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date participant completed the required nine (9) individual counseling
sessions: \_\_\_\_\_\_\_\_\_\_\_\_\_

Counselor's signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date participant completed the required thirty-six (36) group sessions:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date participant presented their life story in-group:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Group facilitator's signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

To advance to Phase Two (II) you must have attended a minimum of
forty-eight (48) community 12-Step (NA/AA) meetings. You must attach an
original *Proof of Attendance Form* to this Phase Advancement Tracking
Sheet.

Consistent levels of participation in all aspects of treatment are
required in order to advance to Phase Two (II). The following statement
must be agreed to by the entire Drug Court Team in order for transfer to
be approved:

*The above mentioned participant has demonstrated consistent motivation
in the treatment process. Each signature below represents the team
member's recommendation for advancement to Phase II of the Palm Beach
County Drug Court Program.*

Signature of Primary Treatment Counselor: Signature of Supervising
D.O.C. Officer:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

I/we do not recommend this participant for advancement to Phase Two (II)
at this time. The following Reason(s) support(s) my/our decision(s):

Date participant successfully completed Phase One (I) work:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature of Clinical Director Signature: Date approved by Clinical
Director:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

For Office Use Only

Drug Court I.D.#: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Referral Agency I.D.#: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

PHASE II TO PHASE III: PHASE ADVANCEMENT TRACKING SHEET

The following form must be completed by the participant prior to
advancement from Phase Two (II) to Phase Three (III). It is the sole
responsibility of the participant to complete and return this form.
Failure to provide this form will result in postponement of advancement
until the completed form is presented. The participant must also be
current with all other program requirements to be considered for phase
advancement.

Participant Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date
of Admission: \_\_\_\_\_\_\_\_\_\_\_\_\_

Date participant completed the required eight (8) individual counseling
sessions: \_\_\_\_\_\_\_\_\_\_\_\_\_

Counselor's signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date participant completed the required thirty-two (32) group sessions:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Group facilitator's signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

To advance to Phase Three (III) you must have attended a minimum of
sixty-four (64) community 12-Step (NA/AA) meetings. You must attach an
original *Proof of Attendance Form* to this Tracking Sheet.

Name of your 12-Step (NA/AA) Sponsor:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Telephone number of your Sponsor (required):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Consistent levels of participation in all aspects of treatment are
required in order to advance to Phase Three (III). The following
statement must be agreed to by the entire Drug Court Team in order for
transfer to be approved:

The above mentioned participant has demonstrated consistent motivation
in the treatment process. Each signature below represents the team
member's recommendation for advancement to Phase III of the Palm Beach
County Drug Court Program.

Signature of Primary Treatment Counselor: Signature of Supervising
D.O.C. Officer:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

I/we do not recommend this participant for advancement to Phase Three
(III) at this time. The following Reason(s) support(s) my/our
decision(s):

Date participant successfully completed Phase Two (II) work:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature of Clinical Director Signature: Date approved by Clinical
Director:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

For Office Use Only

Drug Court I.D.#: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Referral Agency I.D.#: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

PHASE III TO PHASE IV: PHASE ADVANCEMENT TRACKING SHEET

The following form must be completed by the participant prior to
advancement from Phase Three (III) to Phase Four (IV). It is the sole
responsibility of the participant to complete and return this form.
Failure to provide this form will result in postponement of advancement
until the completed form is presented. The participant must also be
current with all other program requirements to be considered for phase
advancement.

Participant Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date
of Admission: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date participant completed the required twelve (12) group sessions:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Group facilitator's signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

To advance to Phase Four (IV) you must have attended a minimum of
forty-eight (48) community 12-Step (NA/AA) meetings .You must attach an
original *Proof of Attendance Form* to this Tracking Sheet.

Name of your twelve 12-Step (NA/AA) Sponsor:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Telephone number of your Sponsor (required):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Consistent levels of participation in all aspects of treatment are
required in order to advance to Phase Four (IV). The following statement
must be agreed to by the entire Drug Court Team in order for transfer to
be approved:

*The above mentioned participant has demonstrated consistent motivation
in the treatment. Each signature below represents the team member's
recommendation for advancement to Phase IV of the Palm Beach County Drug
Court Program.*

Signature of Primary Treatment Counselor: Signature of Supervising
D.O.C. Officer:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

I/we do not recommend this participant for advancement to Phase Four
(IV) at this time. The following Reason(s) support(s) my/our
decision(s):

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date participant successfully completed Phase Three (III) work:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature of Clinical Director Signature: Date approved by Clinical
Director:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

For Office Use Only

Drug Court I.D.#: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Referral Agency I.D.#: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_