Kentucky DUI Assessment

Drug Abuse Screening Test (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 ever gotten in to 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 drugs?*
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 ever had medical problems as a result of your drug use?*
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 ever been treated as an out-patient for problems related to drug abuse?*

I hereby authorize this agency and the court system, the Kentucky Cabinet of Human Services, and the Kentucky Transportation Cabinet to exchange referral information, assessments, treatment summaries, diagnosis, and attendance and participation in treatment for the purposes of notification of admission, evaluation, treatment planning and ongoing treatment and notification of release. I also authorize this agency to exchange the above information with any other agency certified and licensed by the state, to whom I may be referred. *

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Client Rights
I understand that I have the right to fair treatment under the law. This agency shall not discriminate against me in any way. I understand that my rights include, but not limited to: 1. Give informed consent to treatment. 2. Have input into my treatment plan and be informed of it's content. 3. Receive individualized treatment. 4. Submit grievances, recommendations, and opinions regarding my treatment. 5. Give informed written consent regarding participation in human subject research. 6. Receive confidential treatment in compliance with federal and state regulations. These rights have been explained to me and I understand them.*

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Program Requirements
There are several requirements that must be met based upon Kentucky Statutes, the Kentucky Court Systems, and the Cabinet for Human Services. Failure to meet the below requirements will result in the client's case being remanded (returned) to the court. Each client will be required to: 1. Appear for appointments as scheduled. 2. Appear for education and/or group sessions as scheduled. 3. Attend self-help meetings (AA, NA, CA, etc.) as scheduled. 4. Comply with treatment plan. 5. Adhere to Fee Agreement Schedule. Completion papers will not be submitted to the Court until all fees are paid in full. This agency reserves the right to remove any individual from this program due to attendance of any scheduled session under the influence of any mood altering substance. This agency also reserves the right to demand a fluid sample (urine) for drug analysis, or any other form of drug/alcohol testing that this agency deems necessary. Failure to submit to such testing will result in the client's case being remanded to the Court. Suspicion of use is also adequate reason for removal from this program. I understand that this agency offers no guarantee that participation in this program will result in elimination of alcohol or drug abuse on my part. I further waive any and all liability against this agency, it's agents, representatives, and employees. *

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PROGRAM RULES OF CONDUCT
The following are requirements to complete the program:1. Regular attendance 2. Payment required on day of assessment and days of attendance 3. All people you meet and all things discussed will be kept confidential 4. I will come to sessions on time. I will not be permitted to class if I am more than 7 minutes late. 5. Will be respectful to other clients and staff. 6. I will not become violent. 7. I will not cause bodily harm to anyone. 8. I understand that I will be in non-compliance if I miss more than 3 classes (3 weeks) 9. I must work toward treatment goals.*

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Authorization for Release of Information
I hereby authorize DUI Programs of KY and the KY Transportation Cabinet to exchange referral information, assessments, treatment summaries, diagnosis, attendance and participation in treatment for the purpose of notification of admission, evaluation, treatment planning, ongoing treatment and notification of release.*

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FREEDOM OF CHOICE STATEMENT
My signature below confirms that I plan to complete an assessment with DUI Programs of KY. The assessor has provided me a list (including fees) of the other programs within this service area that are certified to provide the level of care for which I have been assessed. I further confirm that I have been given freedom of choice in my selection of a DUI program. This agency will not charge a fee of any description to transfer me to another program, monitor my progress or to distribute my paperwork upon completion. https://providerdirectory.dbhdid.ky.gov/ProviderDirectory.aspx?ptc=DUI *

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Confidentiality Statement
Whatever is discussed during class is strictly confidential. The program staff will not discuss anything personal regarding the participants with anyone outside of the program. Participants also are expected to abide by this rule. No video cameras or recording devices are admitted into this program. The privacy and confidentiality of the participants is held in the strictest possible regard. By signing below, you agree to turn your phone off while in confidential areas including any interior or exterior area of the building where there are staff or other clients present.*

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Witness Signature

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Kentucky DUI Assessment

Demographics

Client Rights

Program Requirements

PROGRAM RULES OF CONDUCT

Authorization for Release of Information

FREEDOM OF CHOICE STATEMENT

Confidentiality Statement