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RAASAP
ENROLLMENT FORM
Full Name: _______________________________________________ Social Security Number: ______-___________
(Last)
(First)
(MI)
Email Address: _________________________________
Age: ____________
Sex: ____________
Race: ____________
Level of Education: _________________
Are You Employed? (Circle one) YES NO
Occupation: __________________ Annual Income: ________________
Name of Employer ____________________________________________
Marital Status: ______________ (Single, Married, Divorced, Separated)
Significant Other’s Name: (if applicable): ________________________
Number of Marriages: _____________
Number of Children: _____________________
If Applicable:
Military Status: __________Active __________Honorable Discharge __________Dishonorable Discharge
__________Other
I certify this information is accurate to the best of my knowledge.
Probationer Signature: _______________________________________
Date: ___________________
RAPPAHANNOCK AREA ALCOHOL SAFTEY ACTION PROGRAM
12 Chatham Heights Rd.
Phone: 540-645-6310 www.raasap.com Fredericksburg, VA 22405 [email protected] Fax: 540-645-6304
________________________________________________________________________________
RAASAP OVERVIEW AND FEE POLICY
You have been referred by the Court to the Rappahannock Area Alcohol Safety Action Program (RAASAP). You
may be referred by the Court to RAASAP:
1.
After being convicted of Driving Under the Influence (DUI)
2.
After being convicted of Boating Under the Influence (BUI)
3.
After being convicted of a similar offense in another state
4.
If you have been charged with or convicted of a drinking/drug violation
which could result in driver’s license suspension.
5.
After being convicted or having found facts sufficient to convict of violating
the drug laws of the Commonwealth.
6.
After being convicted of any offense that is alcohol or drug related misdemeanor.
Participation in RAASAP is directed by Court Order and is part of probation for the offense. The Court has placed
you on probation for a period of time as specified on the restricted license order (DC-265 or DC-359).
Section 18.2-271 (E) of the Code of Virginia requires that no restricted license be issued until the defendant is
enrolled in a certified Virginia Alcohol Safety Action Program (VASAP). The Rappahannock Area Alcohol Safety
Action Program is certified by the state VASAP.
To enroll in the RAASAP, you must contact this office to schedule an appointment. You may drop in or call
between the hours of 8:00AM and 4:00PM Monday through Thursday; the office is closed from 11:00AM to
12:00PM for lunch and 8:00AM to 11:00AM on Fridays. The enrollment appointment must be completed within 15
days of being referred by the Court to RAASAP. There is a $25.00 missed appointment fee if you fail to show for
an appointment or fail to reschedule with 24 hours advance notice.
Prior to or on the day of the intake appointment, you must be prepared to pay VASAP fees or make payment
arrangements. All payments must be paid by personal check, money order or bank check. WE DO NOT
ACCEPT CASH! All payments are non-refundable.
INTERVENTION SERVICES
In addition to the probation supervision and monitoring provided by the case manager, you will be referred to
intervention services. You are responsible for costs and fees associated with the following intervention services:
EDUCATION SERVICES includes 20 hours of alcohol and drug education and information taught in 2-hour
weekly sessions.
INTENSIVE EDUCATION SERVICES includes 20 hours of weekly group sessions (each session is
approximately 2 hours) that take an in-depth look at the role alcohol and drugs play in your life.
TREATMENT SERVICES involve being referred to a treatment agency for further evaluation. If appropriate, you
may be recommended to participate in a combination of group, individual or residential treatment based on your
individual needs.
ASAP Overview Pg. 1
NON-COMPLIANCE
Your case will be referred back to court if you fail to complete an intake interview, if you fail to pay the VASAP
fees, or if you fail to complete any program guidelines. If you are returned to court as non-compliant, the ASAP
fee will NOT be refunded unless court ordered. Should a refund be ordered, $100.00 will be withheld by the
RAASAP to cover the administrative costs of enrollment and intake.
You understand that delinquent balances are subject to the Virginia Debt Set-Off program and other
collection procedures.
PROGRAM FEES
Services Fees
VASAP DUI/RECKLESS DRIVING/BUI
VASAP FIRST OFFENDER DRUG
VASAP HABITUAL OFFENDER
VASAP YOUNG OFFENDER (JUVENILE)
PRE COURT EVALUATION
EDUCATION INTERVENTION (with supervision)
EDUCATION INTERVENTION (JUVENILE)
EDUCATION INTERVENTION
RE-SCHEDULING INTERVENTION
RE-ENSTATEMENT APPOINTMENT
MONITORING
IGNITION INTERLOCK MONITORING
RE-ASSESSMENT
RE-ENTRY
DRIVER IMPROVEMENT
RECKLESS AGGRESSIVE DRIVER
EDUCATION PROGRAM (RADEP)
=
=
=
=
=
=
=
=
=
=
=
=
=
=
$300.00
$300.00
$300.00
$150.00
$175.00
$100.00
$100.00
$100.00 (Education Services only)
$ 25.00 (Education only)
$ 25.00
$ 30.00 per visit*
$ 50.00 per month (no RAASAP probation supervision)
$300.00
$ 50.00
=
$125.00
=
=
=
=
=
=
=
=
=
$
$
$
$
$
$
$
$
$
=
$ 50.00
Administrative Fees
MISSED APPOINTMENT
MAKE UP MISSED CLASS
RETURNED CHECK
DRUG SCREEN
COMPREHENSIVE ALCOHOL SCREEN
SPECIALIZED DRUG SCREEN
VICTIMS IMPACT PANEL
COPY OF FILE
25.00
25.00
35.00
25.00
25.00
40.00
25.00 (without RAASAP probation monitoring)
1.00 1ST PAGE
.50 EVERY PAGE THEREAFTER
* referral for monitoring only or supervision after one year per visit
_____________________________
Probationer Signature
__________________________________________
Date
ASAP Overview & Fee Policy Pg. 2
________________________________
Case Manager/Office Manager
revised 12/2012
RAPPAHANNOCK AREA ALCOHOL SAFETY ACTION PROGRAM
AGREEMENT TO PARTICIPATE
(Not Court Assigned)
I HAVE REQUESTED ENROLLMENT IN THE RAPPAHANNOCK AREA ASAP AND AGREE TO
THE FOLLOWING TERMS OF PARTICIPATION:
1. (a) all fees paid to the RAASAP are non-refundable.
(b) after I have been in the ASAP for 12 months, I am required to pay $30.00 for any case review appointments.
(c) I must pay the cost of any treatment program to which I am referred.
(d) I agree to the Overview Fee Policy of the Rappahannock Area ASAP that specifies additional user fees.
2. Program Participation:
(a) my participation in ASAP will involve a commitment of my time and will not be solely at my convenience. I agree to
meet my ASAP Case Manager at the RAASAP office as required.
(b) I have completed the enrollment process when I have completed the intake interview with the Case Manager.
(c) I agree to attend all program requirements including monitoring case reviews and a final case review.
(d) I will continue with ASAP supervision and requirements until the end of the court-ordered or DMV administrative
period of suspension or revocation of my driver’s license related to this offense.
(e) the minimum service plan will include attending and completing the required education and
or treatment intervention as determined by the Case Manager, attending case-review appointments, community resource
support meetings or identified alternatives, and breath and urine drug screens as required.
(f) I agree to abstain from the use of alcohol or illegal drugs. ASAP staff and instructors (including staff or referring
agencies) will conduct breath and urinalysis tests. I agree to submit to such tests.
(g) Absenteeism will be excused in emergency situations ONLY. (Emergency situations are defined as: a) death or illness, which must
be verified in writing by a physician or, b) work, which must be verified in writing by my supervisor in company letterhead, or c) other
verified emergency situations. I MUST have prior approval from the case manager for class absence. If I miss a scheduled group meeting
or counseling appointment even though I have notified the case manager by phone, my absence will not be excused until the case manager
has received in writing the reason(s) for missing said group or counseling session. I understand that the written excuse must be in the
RAASAP office by 4:00PM the day prior to the next group meeting. I also agree to meet with my case manager prior to the next group
session and make up the group if necessary. Failure to follow the above procedures for a class absence will result in me being removed
from that group.
(h) failure to keep the terms of this agreement shall result in being discharged from the program as unsuccessful.
ACTIONS THAT SHALL RESULT IN DISCHARGE FROM THE PROGRAM AS UNSUCCESSFUL:
1. Failure to complete a scheduled intake appointment or any other scheduled appointment.
2. Failure to cooperate in the initial intake evaluation and investigation of your case by the Case Manager.
3. Failure to actively participate and behave/interact appropriately in any education or treatment intervention.
4. Absence from any scheduled counseling session or education class session without the approval of the Case Manager.
5. Appearing for any activity or program appointment while under the influence of alcohol or other drugs.
6. More than one positive breath or urine drug screen.
7. A subsequent alcohol or drug related arrest.
ENROLLMENT PRIOR TO CONVICTION
I agree to attend the pre-court program for 12 months unless I am convicted of this offense prior to the end of the twelve-month
period. If convicted of this offense, I will continue with ASAP supervision and requirements until the end of the suspension period
set by the court. I understand that fees are not refundable regardless of the outcome of my pending charge.
I HAVE READ THE ABOVE AND UNDERSTAND THE TERMS AND CONDITIONS OF MY PARTICIPATION IN ASAP
___________________________
(INITIAL ENROLLMENT DATE)
________________________________________
(CLIENT SIGNATURE)
___________________________
(INTAKE DATE)
________________________________________
(CASE MANAGER SIGNATURE)
08/14
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