Drug Offender Education Forms

Name

First NameMiddle NameLast Name

E-mail Address

Sex

FemaleMale

Ethnicity

Marital Status

Driver's License Number

Driver's License State

Social Security Number

No dashes or spaces

Birth date

MonthDayYear

Home Address

Street Address

Street Address Line 2

CityState

Zip Code

Cell Phone Number

Home Phone Number

Employer

Probation Officer

How many times have you been married?

How many adults, other than yourself, live with you?

How many children live with you?

Do you feel your drinking/drugging has contributed to family problems at any time in your life?

YesNo

Why do you feel drinking/drugging has contributed to family problems?

How many years of schooling have you completed?

Highest School Grade Completed?

What type of work have you been trained to do?

Are you currently employed in the type of work you've been trained to do?

YesNo

What age did you begin drinking/using drugs?

Have you been arrested prior to your current conviction?

YesNo

Was it Alcohol or Drug related?

YesNo

At what age were you when arrested for your first offense?

At what age were you arrested for your first alcohol/drug related offense?

How many times have you been arrested, prior to your current arrest?

Previous Arrest 1: Month and Year

Previous Arrest 1: What was the charge?

Previous Arrest 2: Month and Year

Previous Arrest 2: What was the charge?

Previous Arrest 3: Month and Year

Previous Arrest 3: What was the charge?

Previous Arrest 4: Month and Year

Previous Arrest 4: What was the charge?

Previous Arrest 5: Month and Year

Previous Arrest 5: What was the charge?

Please select the Month and Year of your Current Arrest.

What was the charge of your Current Arrest?

Was this arrest DWI related?

YesNo

What was your BAC(Blood Alcohol Concentration)? If you do not know, type "I don not know."

Prior to this arrest, was your license:

OKSuspendedRevokedBusiness Purposes Only

Reason:

County of Conviction

Cause # of Conviction

County of Arrest

Have you ever thought you might have a drinking or drug problem?

YesNo

Have you ever received help from any of the following? Select all that apply.

Name of Agency, if applicable.

Where do you usually drink? Select all that apply.

I understand that information about me and my progress in the DOEP program 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 be released to other individuals for any reason without my signed consent.

Signature*

Date of SIgnature

Name

First NameLast Name

The education course you are attending will give you the opportunity to learn new information and better understand different aspects of your behavior. In order to ensure smooth classroom functioning and to enable all participants to gain the most benefits from the course,

Participants in the program are expected to:

· Participate in group discussions, 1 to 1 sessions, and homework.

· Express opinions and feelings in a way that does not disrupt the class.

· Attend all course sessions in their proper sequence.

· Be on time, late arrivals may be treated as an absence.

· Return from breaks on time.

· Cell Phones must be left in your vehicle or placed on instructor table. We are responsible for protecting your confidentiality. Those who do not comply with the cell phone policy will be dismissed from class and no refund will be made.

· No use of tobacco products during this class. Law requires you remain no less than 25 feet from building entrance if you smoke before class, during breaks or after class.

· Abstain from the use of ALL mood-altering chemicals from now until completion of the program.

· No visitors allowed in class.

· Develop a Personal Action Plan.

· There will be a $20 fee for duplicate certificates of completion.

· Absences: Are not permitted in this program. If you are absent you will be dropped from the class and must reenroll in another class at a later date.

I understand that if in the opinion of the instructor I am disruptive or violate any of this agreement, I will leave immediately when asked to leave class. The court or probation will be notified.

I,First Name Last Name agree to comply with all the above expectations, to attend all class sessions, to complete all assignments as they are assigned, and to fully participate in all class discussions.

Date of Signature

Signature*

Drug Offender Education

Arrest History

Current Arrest

Drug Offender Education Program Agreement

Drug Offender Education Knowledge Pre-Test

DAST

Access 2 Recovery

Drug Offender Education Program