(DOEP) Drug Offender Education Program Form

Drug Offender Education Program Form
Date*

MonthDayYear
Date
Name*

First NameMiddle InitialLast Name
Email*
example@example.com
Cell Phone*
Work Phone
Address*

Street Address

Street Address Line 2

CityState

Zip Code
SS#*
Date of Birth*

MonthDayYear
Date
Age*
DL#*
DL State*
Case/Cause#*
County of Conviction*
Gender*
Ethnicity*
Are you on parole or probation?*
Probation or Parole Officers Name*
Probation or Parole Officers Phone Number*
Parenting ClassesLife Skills ProgramJob ReadinessWomen's IssuesFinanceAnger ManagementOther
I, {name} (client) hereby give my consent to On The Road Again DOEP, whether Probation, Parole or the private sector, to exchange any and all information regarding me and my treatment progress. This release covers all forms of information exchanged whether verbal or written. At any time I may restrict or cancel this release in writing effective upon receipt by: On The Road DOEP or any referring party. Otherwise this will expire one year from the date signed.
Signature (client)*

Clear

Family and Dependents
What is your marital status?*
How many times have you been married?*
How many children do you have?*
How many Adult dependents, other than yourself, are living with you?*
How many Child dependents are living with you?*
Do you feel your drinking or drugging has contributed to family problems at any time in your*
If yes, why?*

For the following questions refer to the past 12 months
1. Have you used drugs other than those required for medical reasons?*
2. Have you abused prescription drugs?*
3. Do you abuse more than one drug at a time?*
4. Can you get through the week without using drugs?*
5. Are you always able to stop using drugs when you want to?*
6. Have you had "blackouts" or "flashbacks" as a result of drug use?*
7. Do you ever feel bad or guilty about your drug use?*
8. Does your spouse (or parents) ever complain about your involvement with*
9. Has drug abuse created problems between you and your spouse or your parents?*
10. Have you lost friends because of your use of drugs?*
11. Have you neglected your family because of your use of drugs?*
12. Have you been in trouble at work because of drug abuse?*
13. Have you lost a job because of drug abuse?*
14. Have you gotten into fights when under the influence of drugs?*
15. Have you engaged in illegal activities in order to obtain drugs?*
16. Have you been arrested for possession of illegal drugs?*
17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?*
18. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)?*
19. Have you gone to anyone for help for a drug problem?*
20. Have you been involved in a treatment program specifically related to drug use?*

Texas Drug Offender Education Program Knowledge Test
1. Which of the Stages of Change refers to the stage when a person has not considered a behavior?*
1. (Admin) Which of the Stages of Change refers to the stage when a person has not considered a behavior?
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?*
2. (Admin) Which of the following is the length of driver's license suspension for a drug conviction in Texas for persons 21 years and older?
3. Which schedule of drugs has the highest potential for abuse and carries the severest penalties?*
3. (Admin) Which schedule of drugs has the highest potential for abuse and carries the severest penalties?
4. Which of the Stages of Change is the stage when a person gets busy taking action that specifically addresses changing the problem behavior?*
4. (Admin) Which of the Stages of Change is the stage when a person gets busy taking action that specifically addresses changing the problem behavior?
5. The law that required over the counter medicine to reveal the contents of the drugs was:*
5. (Admin) The law that required over the counter medicine to reveal the contents of the drugs was:
6. Which of the following drugs has been around since ancient times?*
6. (Admin) Which of the following drugs has been around since ancient times?
7. During the Civil War, an addiction to _________________ was known as "the soldiers addiction"?*
7. (Admin) During the Civil War, an addiction to _________________ was known as "the soldiers addiction"?
8. The part of the brain that controls a person's ability to process information is:*
8. (Admin) The part of the brain that controls a person's ability to process information is:
9. Which of the following drugs is categorized as a "stimulant"?*
9. (Admin) Which of the following drugs is categorized as a "stimulant"?
10. Which terms 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.*
10. (Admin) Which terms 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.
11. Which of the following terms means that tolerance to one drug may also produce tolerance to other similar acting drugs?*
11. (Admin) Which of the following terms means that tolerance to one drug may also produce tolerance to other similar acting drugs?
12. _________________ is a condition where loss of control over the use of a drug occurs, in spite of unpleasant consequences.*
12. (Admin) _________________ is a condition where loss of control over the use of a drug occurs, in spite of unpleasant consequences.
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?*
13. (Admin) 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?
14. Which of the following has been identified as an "HIV high risk" behavior?*
14. (Admin) Which of the following has been identified as an "HIV high risk" behavior?
15. The length of time between becoming infected with HIV and the possibility of transferring HIV to another person is:*
15. (Admin) The length of time between becoming infected with HIV and the possibility of transferring HIV to another person is:
16. The use of drugs by some celebrities mistakenly _______________ impact drug use can have on a person's life.*
16. (Admin) The use of drugs by some celebrities mistakenly _______________ impact drug use can have on a person's life.
17. Which of the following describes "values?"*
17. (Admin) Which of the following describes "values?"
18. Which of the following describes "attitudes?"*
18. (Admin) Which of the following describes "attitudes?"
19. Which of the following reflects the latest medical thinking regarding addiction?*
19. (Admin) Which of the following reflects the latest medical thinking regarding addiction?
20. Setbacks or returning to old behaviors that may lead to using drugs is:*
20. (Admin) Setbacks or returning to old behaviors that may lead to using drugs is:
21. Which of the following is not an advantage of 12 Step Support Groups?*
21. (Admin) Which of the following is not an advantage of 12 Step Support Groups?
22. Which of the following is an example of Physiological Needs according to Maslow's hierarchy?*
22. (Admin) Which of the following is an example of Physiological Needs according to Maslow's hierarchy?
23. During the Contemplation Stage going back and forth between the pros and cons of changing a behavior is known as:*
23. (Admin) During the Contemplation Stage going back and forth between the pros and cons of changing a behavior is known as:
24. Which of the following is a reason that planning is important?*
24. (Admin) Which of the following is a reason that planning is important?
25. Which of the following can act as a barrier to reaching our goals?*
25. (Admin) Which of the following can act as a barrier to reaching our goals?
Should be Empty:

Family and Dependents

Education

Employment

Arrest Information

For the following questions refer to the past 12 months

Texas Drug Offender Education Program Knowledge Test