• PERSONAL DATA FORM

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • How many dependents, other than yourself live with you?

  • Do you feel your drinking or drugging has contributed to family problems at any time in your life?*

  • EDUCATION

  • Highest school grade completed?*
  • Are you employed in the type of work you've been trained to do at this time?*

  • DEMOGRAPHIC

  • SEX*
  • ETHNICITY*
  • MARITAL STATUS*

  • ARREST INFORMATION

  • Prior to this arrest, was your license...*

  • Your age when you...
    ...began drinking     
    ...were arrested for first offense     
    ...were arrested for first alcohol-related offense      

  • If charged with DWI, what was the BAC?
    Present Arrest    Others       

  • OTHER INFORMATION

  • Have you ever thought you might have a drinking problem?*
  • Have you ever received help from ...(Check all that apply)*

  • (Name      ) (Explain:      )

  • Where do you usually drink? ...(Check all that apply)*

  • NDP - ADAPTED

  • Please read each questions carefully, and then check the most correct answer in the box provided. 

  • 1. How many times have you been arrested on charges involving alcohol? (Do not count the present DWI arrest.)    (Times)

  • 2. Is someone close to you concerned about your drinking?*
  • 3. With whom did you do most of your drinking before this arrest?*
  • 4. Do you believe your drinking may be causing you problems?*
  • 5. Do you want help for a drinking problem?*
  • 6. Do you feel you are a normal drinker?*
  • 7. Have you ever awakened the morning after some drinking the night before and found you could not remember a part of the evening before?*
  • 8. Does your wife, husband, a parent, or other near relative ever worry or complain about your drinking?*
  • 9. Can you stop drinking without a struggle after one or two drinks?*
  • 10. Do you ever feel bad about your drinking?*
  • 11. Do your friends or relatives think you are a normal drinker?*
  • 12. Do you ever try to limit your drinking to certain times of the day or to certain places?*
  • 13. Are you always able to stop drinking when you want to?*
  • 14. Have you ever attended a meeting of Alcoholics Anonymous?*
  • 15. Have you gotten into fights when drinking?*
  • 16. Has drinking ever created problems between you and your wife, husband, parent, or other near relative?*
  • 17. Has your wife, husband, a parent, or other near relative ever gone to anyone for help about your drinking?*
  • 18. Have you ever lost friends because of drinking?*
  • 19. Have you ever gotten into trouble at work because of drinking?*
  • 20. Have you ever lost a job because of drinking?*
  • 21. Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking?*
  • 22. Do you drink before noon fairly often?*
  • 23. Have you ever been told you have liver trouble? Cirrhosis?*
  • 24. After heavy drinking, have you ever had Delirium Tremens (DT's) or severe shaking?*
  • 25. After heavy drinking, have you ever heard voices or seen things that weren't really there?*
  • 26. Have you ever gone to anyone for help about your drinking?*
  • 27. Have you ever been in hospital because of drinking?*
  • 28. Have you ever been a patient in psychiatric hospital or on a psychiatric ward of a general hospital?*
  • 29. Have you ever been in a hospital to be "dried out" (detoxified) because of drinking?*
  • 30. Have you ever been in jail, even for a few hours, because of drunk behavior?*
  • Should be Empty: