• WHAT IT COST ME

    In order to determine cost of DWI, will you please answer these questions to the best of your knowledge at this time?
  • DATE:
     - -
    2 digit month, 2 digit day, 4 digit year

  • In round number, my costs are:

  • BD - I

  • Reason you were stopped:*
  • Was a breath test taken?*

  • (If yes, what was it? . If no, why not? )

  • Was a blood test taken?*

  • (If yes, what was it? )

  • Before my arrest I was,*

  • (If drinking alcohol after work, for how many hours? )
    (If engaged in a recreational activity while using alcohol or drugs, for how many hours? )

  • I had been using (check all that apply)*

  • (If had used Pills, what type: )

  • I was with*

  • During the weekdays, I tend to drink or use drugs on (place the number of drinks/ amount of drugs used next to a.m./p.m.):
    Monday:     #a.m. to       #p.m.
    Tuesday:       #a.m. to      #p.m.
    Wednesday:       #a.m. to      #p.m.
    Thursday:       #a.m. to      #p.m.
    Friday:       #a.m. to      #p.m.

  • During the weekends, I tend to drink or use drugs on (place the number of drinks/ amount of drugs used next to a.m./p.m.):
    Saturday:         #a.m. to        #p.m.
    Sunday:       #a.m. to      #p.m.

  • Summarize any other comments about your drug/alcohol usage and the events leading up to your arrest below:

  • BD - II

    My Personal Action Plan
  • *
  • I can depend on the following people for support in following plan:*
  • I will get the following benefits from following my plan:*
  • Should be Empty: