New Client Information and DACODS

***Please note: Colorado law requires us to collect certain information from you in order to legally report your progress toward DUI requirements, and to produce your DRS (Discharge Referral Summary) at the completion of your treatment. You will need a DRS from us to prove your progress and/or completion to both the DMV and any judicial supervising agencies, such as probation or court.

IF YOU ARE ENROLLING TO SATISFY COURT REQUIREMENTS FOR DUI OR DMV REQUIREMENTS FOR YOUR DRIVING PRIVILEGES, YOU MUST COMPLETE THIS SECTION. IF THERE ARE ANY QUESTIONS LEFT UNANSWERED, IT COULD HINDER OR INTERRUPT YOUR INTAKE PROCESS AND THE ABILITY TO BEGIN SERVICES AT THIS AGENCY. PLEASE TAKE TIME TO ANSWER EACH QUESTION IN FULL. THANK YOU!

Days waited for treatment *

Days or months since drug or alcohol related driving offense

Prior treatment? *

Yes No

Gender/Identified Gender *

Male Female

Pronouns

He/Him/His She/Her/Hers They/Them/theirs

Pregnant? *

Yes No N/A

Primary race/ethnicity *

Monthly income *

No. of dependents *

Military Service? *

Yes No

Current living situation? *

Independent (live away from parents) Dependent (live with parents or guardian) Dependent (live in supervised setting)

Client disability? *

No Yes (if yes, please describe below)

Highest grade completed *

Current employment status? *

Full-time Part-time Unemployed

Source of income? *

Wages Other

Health Insurance? *

Yes No

If yes, does it cover treatment?

Yes No

Family problems? *

None Slight Moderate Severe

Social problems? *

None Slight Moderate Severe

Employment problems? *

None Slight Moderate Severe

Medical problems? *

None Slight Moderate Severe

Primary drug of choice *

Secondary drug of choice *

How many days in the past 30 days did you use *

Age first used *

Number of DUI arrests in the past 24 months *

Number of all other arrests in the past 24 months *

Out of state client? *

Yes No

Tobacco user? *

Yes No

If former or current tobacco user, did you...

Smoke Vape Chew Snuff

Engage in behavior that puts you at risk of infectious disease? *

Yes No

Engage in behavior that puts you at risk of contracting HIV? *

Yes No

Solace Counseling Services

CASE INFORMATION (if not sentenced, or DMV case only, please enter N/A where applicable)

TREATMENTS

INSURANCE INFORMATION

SOLACE COUNSELING SERVICES