DWI Intervention Program Registration *SECOND TIME OFFENDER* *30 Hour Course, 15 Weeks* "*" indicates required fields Δ TEXAS DWI INTERVENTION PROGRAM PERSONAL DATA FORMI will take my class in...*In personZoomEmail used in Zoom* Referred byAttorneyCourt OrderProbationParoleSelf ReferredPre-TrialOtherName* First Middle Last Date of Birth* Driver's License Number:Address*Phone*Race/Ethnicity:*Date of Birth* Gender* Male Female Present Marital Status:* Never married Married Divorced Separated Widowed Other How many times have you been married?*How many children do you have?*Do you feel your drinking has contributed to any marital problems now or in the past?* Yes No N/A How many years of schooling have you completed?*What type of work have you been trained to do?List the types of jobs you have held:INFORMATION CONCERNING THE ARREST THAT BROUGHT YOU HERE Date of arrest* Time of arrest* Hours : Minutes AM PM AM/PM Speed you were traveling:*Lawful speed:Was an accident involved?* Yes No Was anyone injured?* Yes No Was anyone killed?* Yes No How many?*How many?Has your license ever been under any of these conditions? (including now)* Suspended Revoked Business purposes only If your license was suspended or revoked before this arrest, for what reason did the action occur?*What was the status of your license at the time of the arrest that brought you here?* OK Revoked Suspended Business purposes only Have you ever attended a basic DWI education course offered in Texas?*If yes, when?How many times have you been arrested for any reason?*If any, list charges:Number of arrests which involved alcohol?Age at first arrest:Age at your first alcohol-involved arrest?At what age did you begin drinking?*Have you ever thought you might have an alcohol or drug problem?* Yes No If so, have you ever received help? Yes No N/A If so, have you ever received help? Alcoholics Anonymous Church Alcohol rehabilitation program Psychiatrist Relative Agency Other Please give the agency namePlease explainI understand that information about my progress in the Texas DWI Intervention Program will be used for research purposes and will be shared with the Court and do hereby authorize such use, with the further understanding that this information will otherwise be held confidential and not released to other individuals for any reason without my signed consent.Signature*Your NameYour NameYour NameYour NameCONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATIONI,*authorize DWI Intervention Program to disclose to Martinez & Associates Counseling Services the following information:*The purspose of the disclosure authorized in this is to:*I understand that all Offender Education Programs shall abide by and obtain any consent to disclosure required by applicable Federal and State laws regarding confidentiality of patient/client records including, as applicable and without limitation, 42 United States Code §290dd-2; 42 Code of Federal Regulations, Part 2, and Health and Safety Code, Chapter 611. I understand my records cannot be disclosed without my written consent unless otherwise provided for by the regulations. I also understand that I may revoke this consent in writing at any time except to the extent that action has been taken in response to it, and in any event, this consent expires automatically as follows. Date*Signature*Your NameYour NameYour NameYour NamePlease upload your ID*Max. file size: 4 MB. Please upload your referral form / any documents of referralMax. file size: 4 MB. PRETEST NDP - ADAPTED1. How many times have you been arrested on charges involving alcohol? (Do not count the present DWI arrest.)*2. Is someone close to you concerned about your drinking?* Yes No 3. With whom did you do most of your drinking before this arrest?* Husband/Wife Relative Friends Strangers Alone 4. Do you believe your drinking may be causing you problems?* Yes No, but it used to cause me problems No Not Sure 5. Do you want help for a drinking problem?* Yes No Not Sure 6. Do you feel you are a normal drinker?* Yes No 7. Have you ever awakened in the morning after some drinking the night before and found you could not remember a part of the evening before?* Yes No 8. Does your wife, husband, a parent, or other near relative ever worry or complain about your drinking?* Yes No 9. Can you stop drinking without a struggle after one or two drinks?* Yes No 10. Do you ever feel bad about your drinking?* Yes No 11. Do your friends or relatives think you are a normal drinker?* Yes No 12. Do you ever try to limit your drinking to certain times of the day or to certain places?* Yes No 13. Are you always able to stop drinking when you want to?* Yes No 14. Have you ever attended a meeting of Alcoholics Anonymous?* Yes No 15. Have you gotten into fights when drinking?* Yes No 16. Has drinking ever created problems between you and your wife, husband, parent, or other near relative?* Yes No 17. Has your wife, husband, a parent, or other near relative ever gone to anyone for help about your drinking?* Yes No 18. Have you ever lost friends because of drinking?* Yes No 19. Have you ever gotten into trouble at work because of drinking?* Yes No 20. Have you ever lost a job because of drinking?* Yes No 21. Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking?* Yes No 22. Do you drink before noon fairly often?* Yes No 23. Have you ever been told you have liver trouble? Cirrhosis?* Yes No 24. After heavy drinking, have you ever had Delirium Tremens (DT's) or severe shaking?* Yes No 25. After heavy drinking, have you ever heard voices or seen things that weren't really there?* Yes No 26. Have you ever gone to anyone for help about your drinking?* Yes No 27. Have you ever been in the hospital because of drinking?* Yes No 28. Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital?* Yes No 29. Have you ever been in a hospital to be "dried out" (detoxified) because of drinking?* Yes No 30. Have you ever been in jail, even for a few hours, because of drunk behavior? (Count the present arrest)* Yes No "Services offered via zoom, phone call, in person, and facetime."
