TX Drug Offender Education Program-DOEP Course Registration "*" indicates required fields Δ TEXAS DRUG OFFENDER EDUCATION PROGRAM PERSONAL DATA FORMI will take my class in...*In personZoomEmail used in Zoom* Referred byAttorneyCourt OrderProbationParoleSelf ReferredPre-TrialSAPOtherNAME & ADDRESSName* First Middle Last Drivers License:State:Phone*Date of birth* Address* Street Address City State / Province / Region ZIP / Postal Code DEMOGRAPHICSex:*MaleFemaleEthnicity:*WhiteHispanicAmerican IndianBlackAsianOtherMarital Status:*MarriedNever MarriedSeparatedDivorcedWidowedSingleFAMILY & DEPENDENTSHow many times have you been married?*How many children?*How many dependents, other than yourself live with you?*Adults:Children:Do you feel your drinking has contributed to family problems at any time in your life?* Yes No Why?EDUCATIONHow many years of schooling completed?*Highest school grade completed?*NoneGED/HS diplomaBachelorsMastersDoctorateWhat 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?YesNoEMPLOYMENTList all jobs you held in the past 3 years, beginning with your present job. Give a description of the type of job, year of employment, and reason for leaving:*Job Description:Year of Employment:Reason for Leaving: Add RemoveHow much total time were you unemployed in the last 3 years?*ARREST INFORMATION Dates of current and previous arrest and charges:*Date of Arrest (Year):Charge: Add RemoveIf charged with DWI, what was the BAC?*Present Arrest:Others:How many times has your license now or ever been:Suspended:*Revoked:*Business Purposes Only:*Prior to this arrest, was your license:* OK Suspended Revoked Business Purpose Only Reason:*Your age when you: Began drug activities:*Began drinking alcohol:*Were arrested for first offense:*Were arrested for first drug-related offense:*What are your drugs of choice?*OTHER INFORMATIONHave you ever thought you might have a drug problem?* Yes No Have you ever thought you might have a drinking problem?* Yes No Have you ever received help from:* Family doctor Psychiatrist/psychologist Church Relative/friend Drug/Alcohol rehab program Alcoholics Anonymous Narcotics Anonymous Agency Other Name:Explain:Where do you usually use drugs?* Party or social event Home, by self Home, with family, friends Night club Work or School On the street Other CONSENT FOR THE RELEASE OF CONFIDENTAL INFORMATIONI,*authorize TX Drug Offender Education Course-DOEP to disclose to Martinez & Associates Counseling Services the following information:The purpose of the disclosure authorized in this is to:*I understand my records are protected under Federal Confidentiality Regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in response to it, (e.g., probation, parole, etc.) and that in any event, this consent expires automatically as described below.Executed this:* 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. PRE TEST TEXAS DRUG OFFENDER EDUCATION PROGRAM KNOWLEDGE TEST1. Which of the Stages of Change refers to the stage when a person has not considered a behavior?* A. Action B. Contemplation C. Preparation D. Pre-contemplation 2. Which of the following is the length of driver's license suspension for a drug conviction in Texas for persons 21 years and older?* A. one year B. three months C. 90 days D. 180 days 3. Which schedule of drugs has the highest potential for abuse and carries the severest penalties?* A. Schedule I B. Schedule II C. Schedule III D. Schedule IV E. Schedule V 4. Which of the Stages of Change is the stage when a person gets busy taking action that specifically addresses changing the problem behavior?* A. Relapse B. Contemplation C. Action D. Maintenance 5. The law that required over-the-counter medicine to reveal the contents of the drugs was:* A. Harrison Narcotic Act of 1914 B. Controlled Substances Act of 1970 C. Pure Food and Drug Act of 1906 D. The Federal Narcotics Act of 1956 6. Which of the following drugs has been around since ancient times?* A. Heroin B. Crack C. LSD D. Alcohol 7. During the Civil War, an addiction to _____ was known as "Soldier's Disease"?* A. Heroin B. Opium C. Morphine D. Cocaine 8. The part of the brain that controls a person's ability to process information is:* A. Vital Functions Center B. Higher Learning Center C. Muscle Control Center D. Autonomic Nervous System 9. Which of the following drugs is categorized as a "stimulant"?* A. Alcohol B. Barbiturate C. Cocaine D. Cannabis 10. Which term listed below explains the following effect of drug use: Repeated exposure to the same dose of drug results in diminishing effect. Therefore, increased doses are required to achieve the desired effect.* A. Tolerance B. Cross tolerance C. Withdrawal D. Dependence 11. Which of the following terms means that tolerance to one drug may also produce tolerance to other similar-acting drugs?* A. Withdrawal B. Dependence C. Tolerance D. Cross tolerance 12. A condition where loss of control over the use of a drug occurs, in spite of unpleasant consequences.* A. Dependence B. Tolerance C. Cross tolerance D. Denial 13. Which term identifies one of the biggest problems in dealing with drug dependency because it keeps the dependent person from clearly seeing the effects of his/her drug use?* A. Denial B. Tolerance C. Cross dependence D. Cross tolerance 14. Which of the following has been identified as an "HIV high risk" behavior?* A. Unprotected sex B. Sharing dirty needles C. Drug use D. All of the above are "high HIV risk" behaviors. 15. The length of time between becoming infected with HIV and the possibility of transferring HIV to another person is:* A. immediately B. 3 months C. 6 months D. 1 year or more 16. The use of drugs by some celebrities'* A. glamorizes B. overstates the negative the impact drug use can have on a person's life. C. understates the positive D. ignores 17. Which of the following describes "values?* A. How we act B. Basic beliefs - rules by which we live C. Feelings 18. Which of the following describes "attitudes?"* A. Our positions or views on situations B. Our responses to stress C. Our behaviors - the way we act 19. Which of the following reflects the latest medical thinking regarding addiction?* A. That it is a moral weakness. B. That it is a brain chemistry disease. C. That it is a sin. D. That it is bad luck. 20. Setbacks or returning to old behaviors that may lead to using drugs is:* A. Abstinence B. Sobriety C. Recovery D. Relapse 21. Which of the following is not an advantage of 12-Step Support Groups?* A. Encourages self evaluation and growth B. Provides a safe, supportive environment C. Provides a place for detoxification D. Provides drug-free social contacts 22. Which of the following is an example of Physiological Needs according to Maslow's hierarchy?* A. Friends and Family B. Food C. Self-Fulfillment D. The recognition of others. 23. During the Contemplation Stage going back and forth between the pros and cons of changing a behavior is known as* A. Ambivalence B. Procrastination C. Denial D. Resignation 24. Which of the following is a reason that planning is important?* A. Breaks the future into smaller steps. B. Gives a sense of order. C. Creates ownership. D. All of the above. 25. Which of the following can act as a barrier to reaching our goals?* A. Recovery B. Contemplation C. Procrastination D. None of the above. These questions refer to the past 12 months.1. Have you used drugs other than those required for medical reasons?* Yes No 2. Have you abused prescription drugs?* Yes No 3. Do you abuse more than one drug at a time?* Yes No 4. Can you get through the week without using drugs?* Yes No 5. Are you always able to stop using drugs when you want to?* Yes No 6. Have you had "blackouts" or "flashbacks" as a result of drug use?* Yes No 7. Do you ever feel bad or guilty about your drug use?* Yes No 8. Does your spouse (or parents) ever complain about your involvement with drugs?* Yes No 9. Has drug abuse created problems between you and your spouse or your parents?* Yes No 10. Have you lost friends because of your use of drugs?* Yes No 11. Have you neglected your family because of your use of drugs?* Yes No 12. Have you been in trouble at work because of drug abuse?* Yes No 13. Have you lost a job because of drug abuse?* Yes No 14. Have you gotten into fights when under the influence of drugs?* Yes No 15. Have you engaged in illegal activities in order to obtain drugs?* Yes No 16. Have you been arrested for possession of illegal drugs?* Yes No 17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?* Yes No 18. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)?* Yes No 19. Have you gone to anyone for help for a drug problem?* Yes No 20. Have you been involved in a treatment program specifically related to drug use?* Yes No "Services offered via zoom, phone call, in person, and facetime."
