Client Face Sheet (Level 2 Therapy)
Date of Birth:
Street Address Line 2
State / Province
Postal / Zip Code
Driver's License Number
County where you live:
Cell phone Number
Cell phone Carrier Sprint, T-Mobile, etc:
Did your DUI happen in Colorado?
County where your DUI happened:
Including this one, how many DUI/ DWAI’s have you had?
Was your DUI related to Alcohol, Marijuana, or Prescription Medication?
Did you do a breathalyzer, blood test or refuse?
What was your BAC level?
Have you been assigned a Probation Officer?
Do you have an Attorney or Public Defender?
If currently doing UA’s (Drug Testing) for probation/ pre-trial? What is your UA ID#?
How did you hear about us?
For Level 2 THERAPY, which class time do you prefer (ONLINE VIA ZOOM)? Circle ONE
Do you need an Affidavit of Enrollment for the DMV to reinstate your driver’s license?
Today’s fee will include the Intake ($75) and First Session ($30) = $105
If an Affidavit is needed at intake
, today’s fee will include the Intake ($75), First 2
Sessions ($60), and AOE ($20
Affidavits will be processed within 24
48 hours). = $155
to be directed to the
Should be Empty: