Form MC212 "Summary of Substance Abuse Assessment Report" - Michigan

What Is Form MC212?

This is a legal form that was released by the Michigan Courts - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 1999;
  • The latest edition provided by the Michigan Courts;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MC212 by clicking the link below or browse more documents and templates provided by the Michigan Courts.

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Download Form MC212 "Summary of Substance Abuse Assessment Report" - Michigan

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Original - Court
Approved, SCAO
1st copy - Agent
STATE OF MICHIGAN
CASE NO.
JUDICIAL DISTRICT
SUMMARY OF
JUDICIAL CIRCUIT
SUBSTANCE ABUSE ASSESSMENT REPORT
Court
address
Court telephone no.
1. The defendant,
:
Name
a. was evaluated by this agency on
.
Date
b. failed to report for evaluation.
2. This agency recommends that the defendant:
a. will not benefit from substance abuse service.
b. will benefit from the services specified below. Participation should continue for
.
Period of time
Alcohol Highway Safety Education (AHSE)
Treatment services:
outpatient
inpatient
residential
mental health
3. Comments:
4. Suggested providers:
To be completed on direction of court.
TYPE OF SERVICE
AREA AGENCY(IES) PROVIDING SERVICE
AHSE, Outpatient, Inpatient,
Name, address, and telephone number
Residential or Mental Health
CONFIDENTIAL INFORMATION - NOT TO BE KEPT IN LEGAL CASE FILE
Agency
Signature
Address
Title
City, state, zip
Telephone no.
Date
SUMMARY OF SUBSTANCE ABUSE ASSESSMENT REPORT
MC 212 (6/99)
Original - Court
Approved, SCAO
1st copy - Agent
STATE OF MICHIGAN
CASE NO.
JUDICIAL DISTRICT
SUMMARY OF
JUDICIAL CIRCUIT
SUBSTANCE ABUSE ASSESSMENT REPORT
Court
address
Court telephone no.
1. The defendant,
:
Name
a. was evaluated by this agency on
.
Date
b. failed to report for evaluation.
2. This agency recommends that the defendant:
a. will not benefit from substance abuse service.
b. will benefit from the services specified below. Participation should continue for
.
Period of time
Alcohol Highway Safety Education (AHSE)
Treatment services:
outpatient
inpatient
residential
mental health
3. Comments:
4. Suggested providers:
To be completed on direction of court.
TYPE OF SERVICE
AREA AGENCY(IES) PROVIDING SERVICE
AHSE, Outpatient, Inpatient,
Name, address, and telephone number
Residential or Mental Health
CONFIDENTIAL INFORMATION - NOT TO BE KEPT IN LEGAL CASE FILE
Agency
Signature
Address
Title
City, state, zip
Telephone no.
Date
SUMMARY OF SUBSTANCE ABUSE ASSESSMENT REPORT
MC 212 (6/99)