Kentucky DUI Assessment
We're happy you are here! Step 1: Assessment Forms - Once these forms have been submitted, please return to duiprogramsky.org - Instructions for scheduling your in-person assessment can be found under Step 2. We look forward to meeting you!
*
I understand
Which location are you looking to attend?
*
Lexington
Richmond
Winchester
Demographics
Name
*
First Name
Last Name
MI
Suffix
Address
*
City
*
State
*
County
*
Zip
*
Phone Number
*
-
Area Code
Phone Number
Gender
Male
Female
Marital Status
Unknown
Divorced
Married
Seperated
Single
Race
Unknown
African American
American Indian
Alaska Native
Asian
Hispanic
White
Other
Income
0-9,999
10,000-19,999
20,000-29,999
30,000-39,000
40,000-49,999
50,000-59,999
60,000-69,999
70,000-79,999
80,000-89,999
90,000-99,999
100,000+
Maiden Name/ Other Name
Date of BIRTH
*
-
Month
-
Day
Year
Date
SS# (no dashed)
*
Unknown
No U.S. SSN
Driver's License Number
Suspended License
No U.S. License
Remarks
Assessor Name
Date
-
Month
-
Day
Year
Date
Assessment County Preferred (Fayette, Madison, Clark)
Number of DUI convictions in 5 years (including this one)
*
Lifetime DUI Convictions
*
Notes
Court Case # (Not a required field on this form. This will be required to complete your DUI with the state)
Citation # (not required)
Violation Date (Not a required field on this form. This will be required to complete your DUI with the state)
-
Month
-
Day
Year
Date
Conviction Date (Not a required field on this form. This will be required to complete your DUI with the state)
-
Month
-
Day
Year
Date
Conviction State
*
Conviction County
*
Did your DUI involve alcohol?
*
YES
NO
Was alcohol measured?
*
YES
NO
Reason not measured
Not Requested
Refused
If tested, Method used
Breath
Blood
Urine
BAC (Blood alcohol content at time of DUI)
Did your DUI involve drugs?
*
YES
NO
Drugs involved. Check all that apply
Amphetamines
Inhalants
Cocaine
Marijuana
PCP
Hallucinogens
Opiates
Sedatives
Were drugs tested?
*
YES
NO
Reason not tested
Not requested
Refused
If tested, Method used
Blood
Urine
Other
Notes
Back
Next
Alcohol Use Disorders Identification Test (AUDIT)
1. How often do you have a drink containing alcohol?
*
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
2. How many drinks containing alcohol do you have on a typlcal day when you are drinking?
*
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
3. How often do you have six or more drinks on one occasion?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
4. How often during the last year have you found that you were not able to stop drinking once you had started?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
5. How often during the last year have you failed to do what was normally expected of you because of drinking?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
6. How often in the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
8. How often during the last year have you been unable to remember what happened the night before because of your drinking?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
9. Have you or someone else been injured because of your drinking?
*
No
Yes, but not in the last year
Yes, in the last year
10. Has a relative or friend, doctor or other health care worker been concerned about your drinking or suggested you cut down?
*
No
Yes, but not in the last year
Yes, in the last year
Back
Next
Drug Abuse Screening Test (DAST)
1. Have you used drugs other than those required for medical reasons?
*
YES
NO
2. Have you abused prescription drugs?
*
YES
NO
3. Do you abuse more than one drug at a time?
*
YES
NO
4. Can you get through the week without using drugs (other than those required for medical reasons)?
*
YES
NO
5. Are you always able to stop using drugs when you want to?
*
YES
NO
6. Do you abuse drugs on a continuous basis?
*
YES
NO
7. Do you try to limit your drug use to certain situations?
*
YES
NO
8. Have you had 'blackouts' or 'flashbacks' as a result of drug use?
*
YES
NO
9. Do you ever feel bad about your drug abuse?
*
YES
NO
10. Does your spouse (or parents) ever complain about your involvement with drugs?
*
YES
NO
11. Do your friends or relatives know or suspect you abuse drugs?
*
YES
NO
12. Has drug abuse ever created problems between you and your spouse?
*
YES
NO
13. Has any family member ever sought help for problems related to your drug use?
*
YES
NO
14. Have you ever lost friends because of your use of drugs?
*
YES
NO
15. Have you ever neglected your family or missed work because of your use of drugs?
*
YES
NO
16. Have you ever been in trouble at work because of drug abuse?
*
YES
NO
17. Have you ever lost a job because of drug abuse?
*
YES
NO
18. Have you ever gotten in to fights when under the influence of drugs?
*
YES
NO
19. Have you ever been arrested because of unusual behavior while under the influence of drugs?
*
YES
NO
20. Have you ever been arrested for driving while under the Influence of drugs?
*
YES
NO
21. Have you engaged in illegal activities in order to obtain drugs?
*
YES
NO
22. Have you ever been arrested for possession of illegal drugs?
*
YES
NO
23. Have you ever experienced withdrawal symptoms as a result of heavy drug intake?
*
YES
NO
24. Have you ever had medical problems as a result of your drug use?
*
YES
NO
25. Have you ever gone to anyone for help for a drug problem?
*
YES
NO
26. Have you ever been In a hospital for medical problems related to your drug use?
*
YES
NO
27. Have you ever been involved in a treatment program specifically related to drug use?
*
YES
NO
28. Have you ever been treated as an out-patient for problems related to drug abuse?
*
YES
NO
Back
Next
1. Substance is often taken in larger amounts or over a longer period than was intended. If Present...
*
Alcohol
Amphetamines
Cocaine
Hallucinogens
Inhalants
Marijuana
Opiates
PCP
Sedatives
Other
NONE
2. There is a persistent desire or unsuccessful efforts to cut down or control substance use. If Present...
*
Alcohol
Amphetamines
Cocaine
Hallucinogens
Inhalants
Marijuana
Opiates
PCP
Sedatives
Other
NONE
3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects. If Present...
*
Alcohol
Amphetamines
Cocaine
Hallucinogens
Inhalants
Marijuana
Opiates
PCP
Sedatives
Other
NONE
4. Craving, or a strong desire or urge to use the substance. If Present...
*
Alcohol
Amphetamines
Cocaine
Hallucinogens
Inhalants
Marijuana
Opiates
PCP
Sedatives
Other
NONE
5. Recurrent substance use resulting In a failure to fulfill major role obligations at work, school or home. If Present...
*
Alcohol
Amphetamines
Cocaine
Hallucinogens
Inhalants
Marijuana
Opiates
PCP
Sedatives
Other
NONE
6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance. If Present...
*
Alcohol
Amphetamines
Cocaine
Hallucinogens
Inhalants
Marijuana
Opiates
PCP
Sedatives
Other
NONE
7. Important social, occupational, or recreational activities are given up or reduced because or substance use. If Present...
*
Alcohol
Amphetamines
Cocaine
Hallucinogens
Inhalants
Marijuana
Opiates
PCP
Sedatives
Other
NONE
8. Recurrent substance use In situations In which It is physically hazardous If Present...
*
Alcohol
Amphetamines
Cocaine
Hallucinogens
Inhalants
Marijuana
Opiates
PCP
Sedatives
Other
NONE
9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. If Present...
*
Alcohol
Amphetamines
Cocaine
Hallucinogens
Inhalants
Marijuana
Opiates
PCP
Sedatives
Other
NONE
10. Tolerance, as defined by either of the following: 10-a A need for markedly increased amounts of the substance to achieve intoxication or desired effect. If Present...
*
Alcohol
Amphetamines
Cocaine
Hallucinogens
Inhalants
Marijuana
Opiates
PCP
Sedatives
Other
NONE
10. Tolerance, as defined by either of the following: 10-b A markedly diminished effect in continued use of the same amount of substance.. If Present...
*
Alcohol
Amphetamines
Cocaine
Hallucinogens
Inhalants
Marijuana
Opiates
PCP
Sedatives
Other
NONE
11. Withdrawal, as manifested by either of the following: 11-a The characteristic withdrawal syndrome for the substance. If Present...
*
Alcohol
Amphetamines
Cocaine
Hallucinogens
Inhalants
Marijuana
Opiates
PCP
Sedatives
Other
NONE
11. Withdrawal, as manifested by either of the following: 11-b The substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms. If Present...
*
Alcohol
Amphetamines
Cocaine
Hallucinogens
Inhalants
Marijuana
Opiates
PCP
Sedatives
Other
NONE
Back
Next
Would you or someone you know say you are having or have had a problem with alcohol?
Please Select
Yes - Present
Yes - Past
Not in the last year
NOT APPLICABLE
Would you or someone you know say you are having or have had a problem with pills or illegal drugs?
Please Select
Yes - Present
Yes - Past
Not in the last year
No
Would you or someone you know say you are having or have had problems with other addictions, ie. gambling, pornography or shopping?
Please Select
Yes - Present
Yes - Past
Not in the last year
NO
Is there a family history of addiction in your family?
Please Select
Yes - Present
Yes - Past
Not in the last year
No
If Yes, which family members? Drugs or alcohol?
How are the relationships in your family?
Good
Fair
Poor
Close
Stressful
Distant
Other
How are the relationships in your support system (friends, extended family, etc.?)
Good
Fair
Poor
Close
Stressful
Distant
Other
Are there any problems in your family now? (check all that apply)
Conflict
Abuse
Stress
Loss
Other
Were there any problems with your family in the past? (check all that apply)
Conflict
Abuse
Stress
Loss
Other
Are there any problems in your support system now? (check all that apply)
Conflict
Abuse
Stress
Loss
Other
Were there any problems with your support system in the past? (check all that apply)
Conflict
Abuse
Stress
Loss
Other
Have you ever had problems with marriage/relationships? (check all that apply)
Conflict
Divorce/Separation
Stress
Loss
Trust Issues
Other
Do you have any close friends?
Please Select
Yes
No
Do you have any problems with friendships?
Please Select
Yes
No
Do you get along well with others (neighbors, co-workers, etc.)?
Please Select
Yes
No
What do you like to do for fun?
What is the highest grade you completed in school? (please check)
No Education
K-5
6-8
9-12
GED
College Degree
Masters Degree
Are you currently in school or a training program?
*
Have you ever been arrested for anything other than this DUI? If yes, please list charges and dates:
*
Have you ever been in the hospital for the treatment of mental illness?
*
Please Select
YES
NO
NOT APPLICABLE
If Yes, please describe your experience and diagnosis, if any:
Are you currently on any prescribed medications for mental health?
*
Please Select
YES
NO
NOT APPLICABLE
If so, what medications are you being prescribed?
Back
Next
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.
*
Date
*
-
Month
-
Day
Year
Date
Witness Signature
Date
-
Month
-
Day
Year
Date
Back
Next
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.
*
Date
-
Month
-
Day
Year
Date
Assessor Signature
Date
-
Month
-
Day
Year
Date
Back
Next
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.
*
Date
-
Month
-
Day
Year
Date
Assessor Signature
Date
-
Month
-
Day
Year
Date
Back
Next
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.
*
Date
-
Month
-
Day
Year
Date
Witness Signature
Date
-
Month
-
Day
Year
Date
Back
Next
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.
*
Name
*
First Name
Last Name
SS Number
*
Date
-
Month
-
Day
Year
Date
Witness Signature
Date
-
Month
-
Day
Year
Date
Back
Next
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
*
Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Assessor Signature
Date
-
Month
-
Day
Year
Date
Back
Next
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.
*
Witness Signature
Back
Next
Submit
Should be Empty: