DUI Client Screening/Intake Form Today’s Date Name * Date of Birth * Age * Address * Address Address Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Phone * Alternate Phone Email * Occupation * Employer * Referral * Referral Address * Referral Address Referral Address Referral Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Contact Name * Contact Phone * Fax Referring Court * Date of Court Order to obtain screening How did you hear about us? Emergency Contact Name * Phone Relationship to you * Text Please list your history of DUIs charges (incl. current charge and any dismissed charges) Date BAC State Date BAC State Date BAC State About YOU Ethnicity/Race Marital Status Sex Male Female Number of children Number of siblings Medical Conditions Medications Physicians Name Phone List any arrests (other than DUI) that you have currently pending History of alcohol and/or drug use Alcohol Age of First Use Frequency up to a year? How much at a time? Frequency in past year? Last time used or drank? How much? Marijuana Age of First use Frequency up to a year? How much at a time? Frequency in past year? Last time used or drank? How much? Amphetamines Age of First Use Frequency up to a year? How much at a time? Frequency in past year? Last time used or drank? How much? Opiates/Narcotics Age of First Use Frequency up to a year? How much at a time? Frequency in past year? Last time used or drank? How much? Prescription Drugs Age of First Use Frequency up to a year? How much at a time? Frequency in past year? Last time used or drank? How much? Other Age of First Use Frequency up to a year? How much at a time? Frequency in past year? Last time used or drank? How much? Other Age of First Use Frequency up to a year? How much at a time? Frequency in past year? Last time used or drank? How much? Which of these have you experienced within a 12-month period? A. +1b=1 a. My BAC was .15 or higher at the time of the arrest that led to the current referral. b. I have been arrested or convicted teo or more times for alcohol or drug-related offenses c. I have been unable to control my alcohol or drug use, or I have habitually abused alcohol and/or drugs. d. I admit that I have a problem controlling my alcohol or drug use. e. I have been diagnosed with substance abuse or organic brain disease resulting from substance abuse. f. I have experienced symptoms of withdrawal from alcohol or drug use that included visual, auditory, or tactile hallucinations; convulsive seizures; or delirium tremens. B. 3=1 2=2 a. I have been diagnosed with alcoholic liver disease, alcoholic pancreatitis, or alcoholic cardiomyopathy by a medical doctor. b. My BAC was .08 or higher at the time of the arrest that led to the current referral. c. I have been arrested or convicted one other time for an alcohol or drug-related offense. d. My attendance or productivity at work or school has decreased as a result of drug or alcohol abuse. e. I have experienced family, friends, or social problems associated with drug or alcohol use. f. I have participated in substance abuse education or treatment for problems associated with alcohol or drug use. g. I have experienced drug or alcohol related blackouts. h. I have passed out as a result of drug or alcohol use. i. I have experienced symptoms of withdrawal from alcohol or drug use (including but not exclusive to – shakes, general discomfort, irritability, nausea or anxiety) that was relieved by drinking alcohol or using drugs again. j. I may have psychological dependence on drugs or alcohol. k. I have had increase my consumption to achieve the desired effects. l. I can consume more than I used to without increasing how high or drunk I get. m. My level of tolerance has increased or decreased. n. I have changed the pattern of my alcohol or drug use. o. My personality has changed since I started drinking or using. C. a. Have you given up or reduced important social, occuopational, or recreational activities (hobbies, work, volunteer service, school, friendships etc) because of alcohol or drug use? b. Have you spent a great deal of time in activities necessary to obtain alcohol or drugs, use alcohol or drugs or recover from its effects. c. Have you had any cravings, strong desires, or urges to drink or use? d. Have you used alcohol or drugs more than once in physically hazardous situation such as driving under the influence, operating machinery or power toolset? e. Have you continued to use alcohol or drugs despite knowing that you have persistent or recurrent physical or psychological problems likely to be caused or made worse by alcohol or drugs? f. Have you had alcohol, benzodiazepines, marijuana or other drugs to avoid withdrawal or relieve withdrawal symptoms such as in the morning to avoid a hangover? List any other (not DUI) drug or alcohol related arrests that you have had since you turned 18: History of treatment associated with alcohol or drug use: Date From Date To Agency Name Type of Treatment Date From Date To Agency Name Type of Treatment Are you currently, or in the past been treated for any mental or emotional issues? Yes No If yes, what & when? Have you ever had, or do you currently have any suicidal or homicidal ideation? Yes No If yes, please elaborate: Any family history of mental health issues? Yes No If yes, what? Do you have a relationship with someone who gives you a lot of emotional support? Yes No If yes, who? Do you attend 12-step meetings? Yes No Do you want information on the 12-Step Program Yes No Do you spend a lot of time with your family? Yes No Are your parents still alive? Father Yes Father No Mother Yes Mother No Are your parents still alive? Father Yes Father No Mother Yes Mother No Are your parents still together? Yes No If no, did either or both remarry? Yes No Have you lost any siblings or children to death? Yes No Do you spend a lot of time with people who DO NOT use drugs &/or alcohol? Yes No Do you spend a lot of time with people who DO use drugs &/or alcohol? Yes No Are there children in your household? Yes No What do you like least about yourself? Have the children ever see you drink alcohol? Yes No What do you like most about yourself? Have the children ever seen you do drugs? Yes No Have you ever been to prison? Yes No Have you ever allowed the children to drink or do drugs with you or in your house? Yes No If yes, for how long, when and what was the charge? Have you ever driven under the influence while the children were in the car? Yes No How much education do you have? What type of work do you do? Are you in danger of losing your job? Yes No What would you like to change most about yourself? What do you like least about yourself? What do you like most about yourself? Have you ever been to prison? Yes No If yes, for how long, when and what was the charge? Please describe in DETAIL the circumstances that led to current DUI: Family Patterns of substance use: Relationship (mother, father, sister, brother, grandfather, etc.) Substance(s) of choice Is this person still using or drinking? Comments Relationship (mother, father, sister, brother, grandfather, etc.) Substance(s) of choice Is this person still using or drinking? Comments Relationship (mother, father, sister, brother, grandfather, etc.) Substance(s) of choice Is this person still using or drinking? Comments Have you ever taken medication for psychiatric or emotional problems? Yes No When? What medications? For what? What were the results? What would you like to learn about or accomplish through this program? Thank you for taking the time to complete all these questions. Please sign below to verify that this is information provided by you. Client Signature: * Clear Date Counselor Signature: * Clear Date If you are human, leave this field blank. Submit