DWI Intervention Program Personal Data Form

  • TEXAS DWI INTERVENTION PROGRAM PERSONAL DATA FORM

  • Format: (000) 000-0000.
  • 6. Gender*
  • 7. Date of Birth*
     - -
  • 9. Present Marital Status*
  • 12. Do you feel your drinking has contributed to any marital problems now or in the past?*

  • INFORMATION CONCERNING THE ARREST THAT BROUGHT YOU HERE

  • 16. Date of Arrest*
     - -
  • 22. Was an accident involved?*
  • 23. Was anyone injured?*
  • 25. Was anyone killed?*
  • 27. Has your license ever been under any of these conditions now? (including now)*
  • 29. What was the status of your license at the time of the arrest that brought you here?*
  • 30. Have you ever attended a basic DWI Education course offered in Texas?*

  • If yes, when?       

  • 37. Have you ever thought you might have an alcohol or drug problem?*
  • 38. If so, have you ever received help?*
  • If yes,

  • DWI INTERVENTION PROGRAM AGREEMENT

  • As a participant in this program you must follow these agreements and program requirements:

    • You must participate in group discussions, 1-to-1 sessions, and homework.
    • You may express your opinions and feelings and are free to say whatever you feel as long as it doesn’t disrupt the class.
    • You must bring a significant other (spouse, if married) to Modules 9 and 10, Family week.
    • You must develop an action plan.
    • You must be on time. If you are late (15 min.) or do not show up for class you may be dropped from this program or be required to attend additional group or individual sessions.
    • There will be breaks during class. However, you must return on time.
    • There will be no smoking or eating during class. Smoking during breaks will be permitted in designated areas.
    • No visitors are allowed except during Family Week, Modules 9 and 10.
    • You must abstain from the use of mood altering chemicals throughout this program.
    • You will attend at least two A.A. meetings between Modules 11 and 12.
    • In an emergency situation whereby an absence is unavoidable, you must call your instructor to schedule a make-up session. The make-up should be completed before the next class session. If you fail to make up a missed class session you will be dropped from the program. No more than two absences are allowed.

     

  • Date
     - -

  • SASSI-4 ADULT FORM

  • Please provide one answer, True or False for each question.
    There is no right or wrong answers; just answer the way you feel.
    Answer every question; blank responses are not permitted.

  • 1. People know they can count on me for solutions*
  • 2. Most people make some mistakes in their lives.*
  • 3. I usually “go along” and do what others are doing.*
  • 4. I have never been in trouble with the police.*
  • 5. I was always well behaved in school.*
  • 6. I like doing things on the spur of the moment.*
  • 7. I have not lived the way I should.*
  • 8. I can be friendly with people who do many wrong things.*
  • 9. I do not like to sit and daydream.*
  • 10. No one has ever criticized or punished me.*
  • 11. Sometimes I have a hard time sitting still.*
  • 12. People would be better off if they took my advice.*
  • 13. At times I feel worn out for no special reason.*
  • 14. I am a restless person.*
  • 15. It is better not to talk about personal problems*
  • 16. I have had days, weeks or months when I couldn’t get much done because I just wasn’t up to it.*
  • 17. I’m very respectful of authority.*
  • 18. I come up with good strategies.*
  • 19. I have been tempted to leave home.*
  • 20. I often feel that strangers look at me with disapproval.*
  • 21. Other people would feel apart if they had to deal with what I handle.*
  • 22. I have avoided people I did not want to speak to.*
  • 23. Some crooks are so clever that I hope they get away with what they have done.*
  • 24. My school teachers had some problems with me.*
  • 25. I have never done anything dangerous just for fun.*
  • 26. I need to have something to do so I don’t get bored.*
  • 27. I have sometimes drunk too much.*
  • 28. Much of my life is uninteresting.*
  • 29. Sometimes I wish I could control myself better.*
  • 30. I believe that people sometimes get confused.*
  • 31. Sometimes I am no good for anything at all.*
  • 32. I break more laws than many people.*
  • 33. If some friends and I were in trouble together, I would rather rake the whole blame than tell on them.*
  • 34. Crying does not help.*
  • 35. I think there is something wrong with my memory.*
  • 36. I have sometimes been tempted to hit people.*
  • 37. Most people would lie to get what they want.*
  • 38. I always feel sure of myself.*
  • 39. I have never broken a major law.*
  • 40. There have been times when I have done things I couldn’t remember later.*
  • 41. I think carefully about all my actions.*
  • 42. I have used too much alcohol or “pot”, or used too often.*
  • 43. Nearly everyone enjoys being picked on and made fun of.*
  • 44. I like to obey the law.*
  • 45. I frequently make lists of things to do.*
  • 46. I think I know some pretty undesirable types.*
  • 47. Most people will laugh at a joke now and then.*
  • 48. I have rarely been punished.*
  • 49. I use tobacco regularly.*
  • 50. At times I have been so full of energy that I felt I didn’t need sleep for days at a time.*
  • 51. I have sometimes sat around when I should have been working.*
  • 52. I am often resentful.*
  • 53. I take all my responsibilities seriously.*
  • 54. I do most of my drinking or drug use away from home.*
  • 55. I have had a drink first thing in the morning to steady my nerves or to get rid of a hangover.*
  • 56. While I was a teenager, I began drinking or using other drugs regularly.*
  • 57. One of my parents was/is a heavy drinker or drug user.*
  • 58. When I drink or use drugs I tend to get into trouble.*
  • 59. My drinking or other drug use causes problems between me and my family.*
  • 60. New activities can be strain if I can’t drink or use when I want.*
  • 61. I frequently use non-prescription antacids or digestion medicine.*
  • 62. I have never felt sad over anything.*
  • 63. I have neglected the obligations to family or work because of my drinking or using drugs.*
  • 64. I’m usually happy.*
  • 65. I’m good at figuring out the plot in a spy drama or murder mystery long before the end.*
  • 66. I have wished I could cut down my drinking or drug use.*
  • 67. I am a binge drinker/drug user.*
  • 68. I often use energy drinks or other over-the-counter products to get me through my day.*
  • 69. I’m reluctant to tell my doctors about all the medications I’m using.*
  • 70. My doctors have not prescribed me enough medication to get the relief I need.*
  • 71. I know that my drinking/using drug is making my problems worse.*
  • 72. I have built up a tolerance to the alcohol, drugs, or medications I’ve been using.*
  • 73. Over time I have noticed I drink or use more than I used to.*
  • 74. I have worried about my parent(s)’ drinking or drug use.*

  • SASSI-4 ADULT FORM

  • For each item below, choose the option which reflects how often you have experienced the situation described DURING THE TIME FRAME the administrator has checked below:

  • FVA

    “Drinks” and “drinking” refer to any type alcohol – beer,wine, hard liquor, etc.
  • 1. Had drinks (beer, wine, liquor) with lunch?*
  • 2. Taken a drink or drinks to help you talk about your feelings or ideas?*
  • 3. Taken a drink or drinks to relieve a tired feeling or give you energy to keep going?*
  • 4. Had more to drink than you intended to?*
  • 5. Experienced physical problems after drinking (e.g. nausea, seeing/hearing problems, dizziness, etc.)?*
  • 6. Gotten into trouble on the job, in school, or with the law because of your drinking?*
  • 7. Became depressed after having sobered up?*
  • 8. Argued with your family or friends because of your drinking?*
  • 9. Had the effects of drinking recur after not drinking for a while (e.g., flashbacks, hallucinations, etc.)?*
  • 10. Had problems in relationships because of your drinking (e.g., loss of friends, separation, divorce, etc.)?*
  • 11. Became nervous or had the shakes after having sobered up?*
  • 12. Tried to commit suicide while drunk?*
  • 13. Found myself craving a drink or a particular drug?*

  • SASSI-4 ADULT FORM

  • FVOD

    The word “misuse” means taking medications in larger amounts than prescribed, longer than prescribed, or using medications not prescribed for you. “Drugs” include things like pot, cocaine, meth, heroin, etc.
  • 1. Misused medications or took drugs to improve your thinking and feelings?*
  • 2. Misused medications or took drugs to help you feel better about a problem?*
  • 3. Misused medications or took drugs to become more aware of your senses (e.g., sight, hearing, touch, etc.)?*
  • 4. Misused medications or took drugs to improve your enjoyment of sex?*
  • 5. Misused medications or took drugs to help forget that you feel helpless and unworthy?*
  • 6. Misused medications or took drugs to forget school, work or family pressures?*
  • 7. Gotten into trouble at home, work, or with the police because of medications or drug-related activities?*
  • 8. Gotten really stoned or wiped out on drugs (more than just high)?*
  • 9. Tried to get a hold of some prescription drug (e.g., tranquilizers, pain killers, pills to calm nerves, sleep aids, etc.)?*
  • 10. Spent your spare time in drug-related activities (e.g., talking about drugs, buying, selling, taking, etc.)?*
  • 11. Used drugs or medications and alcohol at the same time?*
  • 12. Kept taking medications or drugs in order to avoid pain or withdrawal?*
  • 13. Felt your misuse of medications, alcohol, or drugs has kept you from getting what you want out of life?*
  • 14. Took a higher dose or different medications than your doctor prescribed in order to get the relief you need?*
  • 15. Used prescription drugs that were not prescribed to you?*
  • 16. Your doctor denied your request for medications you needed?*
  • 17. Been accepted into a treatment program because of misuse of medications, alcohol, or drugs?*
  • 18. Engaged in activity that could have been physically dangerous after (or while) drinking or using drugs or medications?*
  • Should be Empty: