• Drug Offender Education

    Personal Data Form
  • Sex
  • Ethnicity
  • Marital Status
  • Birth date
     - -
  • Do you feel your drinking/drugging has contributed to family problems at any time in your life?
  • Are you currently employed in the type of work you've been trained to do?

  • Arrest History

  • Have you been arrested prior to your current conviction?
  • Was it Alcohol or Drug related?

  • Current Arrest

  • Was this arrest DWI related?
  • Prior to this arrest, was your license:
  • Have you ever thought you might have a drinking or drug problem?
  • Have you ever received help from any of the following? Select all that apply.

  • Where do you usually drink? Select all that apply.

  • I understand that information about me and my progress in the DOEP program will be used for research purposes and will be shared with Probation and do hereby authorize such use, with the further understanding that this information will otherwise be held confidential and not be released to other individuals for any reason without my signed consent.

  • Drug Offender Education Program Agreement

  • The education course you are attending will give you the opportunity to learn new information and better understand different aspects of your behavior.  In order to ensure smooth classroom functioning and to enable all participants to gain the most benefits from the course,

    Participants in the program are expected to:

    · Participate in group discussions, 1 to 1 sessions, and homework.

    · Express opinions and feelings in a way that does not disrupt the class.

    · Attend all course sessions in their proper sequence.

    · Be on time, late arrivals may be treated as an absence.

    · Return from breaks on time.

    · Cell Phones must be left in your vehicle or placed on instructor table.  We are responsible for protecting your confidentiality.  Those who do not comply with the cell phone policy will be dismissed from class and no refund will be made.

    · No use of tobacco products during this class.  Law requires you remain no less than 25 feet from building entrance if you smoke before class, during breaks or after class.

    · Abstain from the use of ALL mood-altering chemicals from now until completion of the program.

    · No visitors allowed in class.

    · Develop a Personal Action Plan.

    · There will be a $20 fee for duplicate certificates of completion.

    · Absences:   Are not permitted in this program.  If you are absent you will be dropped from the class and must reenroll in another class at a later date.

  • I understand that if in the opinion of the instructor I am disruptive or violate any of this agreement, I will leave immediately when asked to leave class. The court or probation will be notified.

  • I, agree to comply with all the above expectations, to attend all class sessions, to complete all assignments as they are assigned, and to fully participate in all class discussions.


  • Drug Offender Education Knowledge Pre-Test

    Select the best answer and place the letter which corresponds to it in the space provided next to the question. Read all answers BEFORE making a choice.
  • 1. 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?
  • 3. Which schedule of drugs has the highest potential for abuse & 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?
  • 5. 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?
  • 7. During the Civil War, "the soldiers addiction" was an addiction to what drug?
  • 8. Which part of the brain controls a person's ability to process information?
  • 9. Which of the following drugs is categorized as a "stimulant?"
  • 10. Which term explains the following effect of drug use: Repeated exposure to the same dose of drug results in diminishing effect. (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?
  • 12. _______________is a condition where loss of control over the use of the 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?
  • 14. Which of the following has been identified as an "HIVhigh risk" behavior?
  • 15. The length of time between becoming infected with HIVand the possibility of transferring HIVto another person is:
  • 16. Use of drugs by some celebrities mistakenly __________ impact drug use can have on a person's life.
  • 17. Which of the following describes "values?"
  • 18. Which of the following describes "attitudes?"
  • 19. 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:
  • 21. 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?
  • 23. During the Contemplation Stage going back and forth between the pros and cons of changing behavior is known as:
  • 24. 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?

  • DAST

  • 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 (other than those required for medical reasons)?
  • 5. Are you always able to stop using drugs when you want to?
  • 6. Do you abuse drugs on a continuous basis?
  • 7. Do you try to limit your drug use to certain situations?
  • 8. Have you had “blackouts” or “flashbacks” as a result of drug use?
  • 9. Do you ever feel bad about your drug abuse?
  • 10. Does your spouse (or parents) ever complain about your involvement with drugs?
  • 11. Do your friends or relatives know or suspect you abuse drugs?
  • 12. Has drug abuse ever created problems between you and your spouse?
  • 13. Has any family member ever sought help for problems related to your drug use?
  • 14. Have you ever lost friends because of your use of drugs?
  • 15. Have you ever neglected your family or missed work because of your use of drugs?
  • 16. Have you ever been in trouble at work because of drug abuse?
  • 17. Have you ever lost a job because of drug abuse?
  • 18. Have you gotten into fights when under the influence of drugs?
  • 19. Have you ever been arrested because of unusual behavior while under the influence of drugs?
  • 20. Have you ever been arrested for driving while under the influence of drugs?
  • 21. Have you engaged in illegal activities in order to obtain drug?
  • 22. Have you ever been arrested for possession of illegal drugs?
  • 23. Have you ever experienced withdrawal symptoms as a result of heavy drug intake?
  • 24. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?
  • 25. Have you ever gone to anyone for help for a drug problem?
  • 26. Have you ever been in a hospital for medical problems related to your drug use?
  • 27. Have you ever been involved in a treatment program specifically related to drug use?
  • 28. Have you been treated as an outpatient for problems related to drug abuse?

  • Access 2 Recovery

    804 E. Moore Avenue Terrell, Texas 75160

  • Drug Offender Education Program

    Exit Interview

  • Completion Date:

     

  • Course Participation:

    __Good              __Satisfactory           __Unsatisfactory

  • Recommendation Based on the Screening Instrument Used

                    Low risk of a drug problem indicated at this time
                    Moderate Level - should be referred for an evaluation
                    Substantial Level- should be referred for an evaluation
                    Severe Level - should be referred for an evaluation

  • Remarks:

     

  • Post-test Score:

  • Sobriety Date:

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