Driving While Intoxicated Ed Program Course REGISTRATION *FIRST TIME OFFENDER ONLY* *12 Hour Course "*" indicates required fields Δ I will take my class in...*In personZoomEmail used in Zoom* Referred byAttorneyCourt OrderProbationParoleSelf ReferredPre-TrialOtherNAME & ADDRESSName* First Middle Last Phone*Date of Birth* Drivers License*State*Address* Street Address City State / Province / Region ZIP / Postal Code How many times have you been married?*How many dependents, other than yourself live with you?* Adults Children AdultsChildrenDo you feel your drinking or drugging has contributed to family problems at any time in your life?* Yes No If yes, why?EDUCATIONHow many years of schooling completed?*Highest school grade completed* None GED/HS diploma Bachelors Masters Doctorate What type of work have you been trained to do?Are you employed in the type of work you've been trained to do at this time? Yes No DEMOGRAPHICSEX* Male Female ETHNICITY* White Black Hispanic Asian American Indian Other MARTIAL STATUS* Married Never Married Separated Divorced Widowed Single ARREST INFORMATIONPrior to this arrest, was your license...* ...OK ...suspended ...revoked ...business purposes only ReasonCause # on this conviction*County of conviction*Your age when you...Began drinking*Were arrested for first offense*Were arrested for first alcohol-related offense*Dates of current and previous arrest and charges:If charged with DWI, what was the BAC?*Present Arrest:Others:Previous arrest and chargesDATE OF ARRESTCHARGE Add RemoveOTHER INFORMATIONHave you ever thought you might have a drinking problem?* Yes No Have you ever received help from:* Family doctor Psychiatrist/psychologist Church Relative/friend Alcohol rehab program Alcoholics Anonymous Agency Other Agency NameExplainWhere do you usually drink?* Party or social drinking Home, by self Home, with family, friends Bar/restaurant Other I understand that information about me and my progress in the DWI school will be used for research purposes and will be shared with Probation 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 DISCLOSURE OF CONFIDENTIAL INFORMATION:I,*hereby consent to communication between DWI ED. COURSE and Martinez Associate and Counseling Services District's office, Public defender's office or Defense Counsel, Community Supervision Correction Department, Court Coordinator of Webb County. The purpose of, and need for, this disclosure is to inform the court and all other named parties of my eligibility and/or acceptability for substance abuse treatment service and my treatment attendance, prognosis, compliance and progress in accordance with the drug treatment court program's monitoring criteria. Disclosure of this confidential information may be made only as necessary for, and pertinent to, hearings and/or reports concerningCourt cause number*I understand that this consent will remain in effect until there has been a formal and effective termination of my involvement with the educational treatment program for the above referenced case, such as the discontinuation of all court supervision upon my successful completion of the educational treatment court requirements OR upon sentencing for violating the terms of my educational treatment court involvement. I understand if I revoke this release of information; I will be terminated from the program. I understand that any disclosure made is bound by Federal Confidentiality Regulations 42 CFR, Part 2; 45 CFR Parts 160 and 164; and Division 10.5 of the Health and Safety Code, which governs the confidentiality of substance abuse patient records and that recipients of this information may re-disclose it only in connection with their official duties.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 DWI EDUCATION COURSE KNOWLEDGE TEST1. In recent years, the percentage of alcohol related traffic deaths in Texas has:* A. No information available B. Stayed the same C. Increased D. Decreased 2. Administrative License Revocation (ALR) relates to:* A. Failing a field sobriety test B. Refusing a field sobriety test C. Failing a breath or blood test D. Refusing a breath or blood test 3. Which of the following is an exception to the Open Container Law?* A. In possession of a passenger B. Out of driver's reach C. In locked storage area D. Vehicle is stopped on side of road 4. The ability related to driving which tends to be first affected by alcohol or other drugs is:* A. Judgment B. Muscle control C. Reaction time D. All of the above 5. The fine for first offense DWI in Texas is:* A. Up to $1,000 B. Up to $2,000 C. Up to $5,000 D. Up to $10,000 6. In Texas, a person gives consent to take a breath or blood test when he/she:* A. Applies for a driver's license B. Operates a motor vehicle in a public place C. Signs his/her driver's license D. Has been drinking or using drugs 7. Alcohol does the following:* A. Stimulates the central nervous system В. Increases mental and physical abili C. Affects all persons the same D. Depresses the central nervous system 8. Alcohol or other drugs affect people differently because of:* A. Tolerance B. Mood C. Fatigue D. All of the above 9. Which of the following beverages contains the most pure alcohol?* A. 12-oz. can of regular beer B. 1-oz. shot of 80 proof whiskey C. 12-oz. bottled cooler D. All have the same amount 10. Which of the following may be a defense against intoxication?* A. Fatigue В. Time C. Drugs D. Sweating 11. Alcohol and most other drugs are mainly removed from the body by:* A. Breath B. Sweat C. Urination D. Liver 12. Which of the following is a factor in determining blood alcohol concentration (BAC)?* A. Emotions B. Physical activity C. Body weight D. None of the above 13. The legal definition of intoxication in Texas is:* A. Being drunk or stoned on drugs. B. Not having normal use of mental or physical faculties because of alcohol or drugs. C. Having a BAC of .08% or more. D. Having a BAC of .08% or more; or not having normal use of mental or physical faculties because of alcohol or drugs. 14. Alcohol affects vision by:* A. Reducing side vision B. Widening side vision C. Enhancing color vision D. Sharpening eye focus 15. The objective of a DWI Education course is to:* A. Convince people not to drink at all B. Encourage attendance at Alcoholics Anonymous and counseling C. Learn about DWI laws and procedures D. Have people carry out responsible decisions 16. Which drug is most likely found in drivers who are in fatal vehicle crashes?* A. Crack B. Marijuana C. Heroin D. Valium 17. The lowest BAC (of those provided) at which all persons have been shown to be affected is:* A. 0.05% B. 0.08% C. 0.10% D. 0.15% 18. The average alcohol elimination rate per hour is:* A. 1 drink B. 0.015% C. 0.05% D. 0.08% 19. Which of the following affects the rate of absorption of alcohol?* A. Physical activity B. Sleep С. Liver function D. Strength of drink 20. Which of the following is a part of the definition of alcoholism?* A. Continued use despite problems B. Regressive abuse C. Disease which is curable D. Disease which is hopeless 21. Which of the following (of those provided) is the best sign of alcoholism?* A. Sleeping after drinking B. Not having a job C. Increased sexual ability D. Drinking alone 22. A DWI conviction which includes a BAC of 16 or greater results in a three year driver's license surcharge of:* A. $1,000 per year B. $1,500 per year C. $1,750 per year D. $2,000 per year 23. The best long-term way to change improper drunken/driver behavior is:* A. Education B. Longer jail term C. Longer license suspension D. Higher fines 24. Combining alcohol and marijuana produces:* A. The same effect B. A greater effect C. A lesser effect D. Greater or lesser depending on person 25. A desirable personal action to prevent a future DWI is:* A. Watch for police closely B. Avoid situations which may lead to drinking and driving С. Drive slowly D. All of the above "Services offered via zoom, phone call, in person, and facetime."
