• 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?*

  • EMPLOYMENT

  • List all jobs you have held in the past 3 years, beginning with your present job. Give a description of the type of job, year of employment, and reason for leaving.

  • DEMOGRAPHIC

  • SEX*
  • ETHNICITY*
  • MARITAL STATUS*

  • ARREST INFORMATION

  • Dates of current and previous arrest and charges:

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

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

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

  • OTHER INFORMATION

  • Have you ever thought you might have a drug problem?*
  • 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 use drugs? ...(Check all that apply)*

  • CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION

    **SAMPLE** (This is a sample. Programs should consult with their legal counsel in regards to a consent form specific to their program.)

  • I understand that all Offender Education Programs shall abide by and obtain any consent to disclosure required by applicable Federal and State laws regarding confidentiality of patient/client records including, as applicable and without limitation, 42 United States Code § 290dd-2; 42 Code of Federal Regulations, Part 2, and Health and Safety Code, Chapter 611. I understand my records cannot be disclosed without my written consent unless otherwise provided for by the regulations. I also understand that I may revoke this consent in writing at any time except to the extent that action has been taken in response to it, and that in any event, this consent expires automatically as follows.

  • DRUG USE QUESTIONNAIRE (DAST-20)

  • OFFICE USE ONLY DAST Score:  

  • The following questions concern information about your potential involvement with drugs not including alcoholic beverages during the past 12 months. Carefully read each statement and decide if your answer is “Yes” or “No”. Then, fill in the appropriate box beside the question.

    When the words drug abuse are used, they mean the use of prescribed or over-the-counter in excess of the directions and any non-medical use of drugs. The various classes of drugs may include: cannabis (e.g., marijuana, hash), solvents, tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD) or narcotics (e.g., heroin). Remember that the questions do not include alcoholic beverages.

    Please answer every question, If you have difficulty with a statement then choose the response that is mostly right.

    These 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 drugs?*
  • 9. Has drug abuse created problems between you and your spouse or your parents?*
  • 10. Have you ever 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 or school because of drug abuse?*
  • 13. Have you lost a job because of drug use?*
  • 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 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?*
  • Should be Empty: