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    DUI Intake Form

    This is a comprehensive intake form that will take 15-30 minutes to complete. It contains 7 parts which include a Pre-/Post DUI Class Test, State Required Questionnaire, Infectious Disease Behavioral Screen, Infectious Disease Medical Screen and a Resilience Survey.

  • PLEASE NOTE, you will need the following to complete this form

    • Name, address and phone number of your probation officer, parole officer, judge or diversion officer.
    • A copy of your probation, parole, court or diversion order, including treatment requirements must be included.

  • Your Contact Information

  • Demographics

  • Gender*
  • Sexual orientation*
  • Primary Race*
  • Hispanic*
  • Veteran Status*
  • Year Entered
     - -
  • Year Exited
     - -
  • Are you pregnant?*
  • Are you a Domestic Violence Victim or Survivor?*
  • Are you actively fleeing a domestic violence situation?*

  • Income

  • Are you receiving any of the following non-cash benefits? (select all that apply)*

  • Homelessness

  • Have you ever experienced homelessness?*
  • Are you currently homeless?*

  • Pre-/Post DUI Class Test

  • Questions 1-11 relate to facts about alcohol, other drugs and driving. Please mark only one answer per row.

  • 1. Which will sober you up?*
  • 2. Which part of the driving task is affected by alcohol consumption?*
  • 3. Which of the following has the highest alcohol content?*
  • 4. Approximately what percentage of the U.S. population does not drink alcohol?*
  • 5. If a person is out at a bar until midnight and drinks to a BAC level of .25, he/she might:*
  • 6. On average, how long does it take the body to eliminate one standard drink from the system?*
  • 7. Which of the following can be signs of alcohol/other drug addiction or dependence?*
  • 8. Which of the following best describes the action of alcohol on the body?*
  • 9. If a person goes to bed at midnight with a blood alcohol concentration (BAC) of .25, about what time will the BAC return to 0?*
  • 10. When a person takes more than one drug:*
  • 11. If three different people drink the exact same amount of alcohol, they will:*

  • Questions 12-20 relate to drinking and driving attitudes and behavior. People feel differently, so there are no “right” or “wrong” answers.

  • 12. If I have just one or two drinks, my driving could be affected.*
  • 13. I would not feel safe riding with a driver who has consumed 6 drinks in 2 hours.*
  • 14. My arrest was nobody’s fault but my own.*
  • 15. I need to change some of my alcohol or other drug use patterns.*
  • 16. I have confidence in my plan to avoid future problems with alcohol or other drugs.*
  • 17. I am less likely to abuse alcohol or other drugs as a result of my arrest experience.*
  • 18. I think coming to this class is a good opportunity to learn important information and plan ahead.*
  • 19. I will not go out drinking again unless I have a way to get home without driving myself.*
  • 20. Changing my behavior involves more than simply promising myself “I’ll change.”*

  • © 2010 The Change Companies®

  • State Required Questionnaire (DACODS)

  • Questionnaire

  • Marital Status*
  • Living Situation*
  • Highest education level*
  • CLIENT UNDER 18: Have you attended school in the last 3 months?
  • Disability*
  • Current Employment*
  • Primary Source of income/support*
  • Primary Source of Payment for our services*
  • Health Insurance (regardless of payment source)*
  • If insured, does your insurance cover substance abuse treatment?*
  • Any additional mental health problems?*
  • Have you (now or ever) experienced or witnessed a traumatic event?*
  • Referral or Transfer Source*
  • Family Issues and Problems*
  • Socialization Problems*
  • Education/Employment Problems*
  • Medical/Physical Problems*
  • Did you get your DUI outside of Colorado?*

  • Substance Use

  • Primary Drug of Choice

  • Secondary Drug of Choice

  • Tertiary Drug of Choice

  • In the six (6) months prior to admission, how many times did you...

  • Have you attended any self-help meetings in the last 30 days?*
  • Do you currently use a Tobacco product?*

  • Out-of-State Offender - Client Questionnaire

  • The following questions must be answered by all clients seeking admission to this program for any education or treatment; as required by Colorado law. Refusal to cooperate, or failure to provide complete or accurate information, including failure to sign a release of information to the referring criminal justice agency, will result in a denial to attend the treatment program and notification of authorities, in accord with the requirements in C.R.S. 17-27.1-101.

  • Are you required to report your treatment progress or completion to any Court, Department of Corrections, Parole, Probation, Adult Diversion Program, or DMV?*
  • Are you, or will you be under the supervision of a Probation or Parole Officer in Colorado?*
  • Are you seeking education or treatment for the sole purpose of restoring you driving privileges as the result of an alcohol or drug related driving offense in another state, but are not under court order to do so?*

  • Upload a copy of your probation, parole, court, or diversion order that includes your court-mandated requirements.

    If you do not have this document you will be required to provide at the time of your intake.

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  • Form C

    Interstate Compact Unit
    940 N Broadway
    Denver, CO 80203
    P 303.763.2408 F 303.861.1548
    DOC_interstatetreatment.state.co.us

    Jared Polis, Governor | Dean Williams, Executive Director

  • Infectious Disease Behavioral Screen

  • INFECTIOUS DISEASE MEDICAL AND BEHAVIORAL SCREENING

    In response to increasing rates of hepatitis B and C, sexually transmitted diseases, TB and HIV, all clients/patients receiving services from substance abuse treatment providers licensed by theAlcohol and Drug Abuse Division (ADAD) shall be screened for past and present risk factors, including those associated with substance abuse, for disease acquisition and transmission. In a joint effort, ADAD, the Colorado Department of Public Health and Environment, substance abuse treatment providers and HIV and hepatitis advocacy groups and coalitions have developed twoScreens for determining client/patient risk. In introducing the Screens to clients/patients the following points should be made (not in preferential order):Administering a screen is required by state regulation;

    • Privacy of responses to screen questions is protected by federal regulation and state law;
    • The screen provides important information to clients/patients about their levels of risk;
    • In order to get the best information, honest, accurate responses to questions are vital.

  • INFECTIOUS DISEASE BEHAVIORAL SCREEN

    The Infectious Disease Behavioral Screen can be self-administered or used in a face-to-face interview. The questions identify behaviors that may place clients/patients at risk for HIV and hepatitis B and C exposure. A scoring instrument for the screen tallies numeric values of client/patient responses and indicates appropriate clinical responses.

    Because of the sensitive nature of the information being collected and the possibility of clients/patients perceptions of personal intrusion, it is recommended that the Screen be administered after some rapport and trust has been established, preferably following HIV and hepatitis education. If self-administered, a counselor or other person knowledgeable about the Screen should be available to assist with any client/patient questions or concerns.

  • I understand that my responses to this screen are protected under the federal regulations governing Confidentiality

    Of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that HIV, STD and TB related information about me is protected by state law and cannot be disclosed unless state law authorizes the disclosure.

    I have read and understand the above.

  • 1. Have you had 2 or more sexual partners in the past 10 years?*
  • 2. Have you had anal sex (penis in anus) with any of your sexual partners during the past 10 years?*
  • 3. How often have you used a condom when having anal sex in the past 10 years?*
  • 4. Have you ever had a sexually transmitted disease such as gonorrhea, syphilis, chlamydia, genital warts (HPV), genital herpes, or hepatitis?*
  • 5. In the last 10 years, have you ever given money or drugs to anyone to have sex with you?*
  • 6. Have you ever had sex with someone so that they would give you money or drugs?*
  • 7. Have you ever injected street drugs, steroids, or vitamins with a needle?*
  • 8. Have any of your sexual partners in the past 10 years ever injected street drugs, steroids, or vitamins with a needle?*
  • 9. Have any of your sexual partners in the past 10 years been men who have had sex with other men?*
  • 10. Have any of your sexual partners in the past 10 years ever had a sexually transmitted disease such as gonorrhea, syphilis, Chlamydia, genital warts (HPV), genital herpes, or hepatitis?*

  • Total your responses above and enter them in the field below using this scoring system.

    1. Yes (5) No (0)

    2. Yes (10) No (0)

    3. Never (20) Sometimes (15) Always (10) No anal sex (0)

    4. Yes (15) No (0)

    5. Yes (10) No (0)

    6. Yes (20) No (0)

    7. Yes (30) No (0)

    8. Yes (30) No (0) Don’t know (15)

    9. Yes (30) No (0) Don’t know (15)

    10. Yes (30) No (0) Don’t know (15)

  • Interpreting Your Score

  • SCORE OVER 120 = HIGH RISK

    A score over 120 indicates you are at high risk for acquiring/transmitting HIV and/or Hepatitis. See your counselor right away for referral to your local county health department or the Colorado Department of Public Health and Environment for further evaluation and follow-up.

     

    SCORE BETWEEN 30-119 = MEDIUM RISK

    A score of 30-119 indicates that you are at medium risk for acquiring/transmitting HIV and/or Hepatitis.

    See your counselor for more information about ways that you can reduce your risk and other programs that can help you.

     

    SCORE BELOW 29 = LOW RISK

    A score of 0-29 indicates that you are at low risk for acquiring HIV and/or Hepatitis. Low risk doesn’t necessarily mean no risk. See your counselor if you have questions or concerns about behaviors that may place a person at risk.

  • YOUR COUNSELOR IS REFERRING YOU TO THE FOLLOWING AGENCY / PROGRAM FOR

    FOLLOW-UP:

    Community Health Services (Pitkin County)

    405 Castle Creek Road, Suite 6 1

    Aspen, CO 81611 

    970-920-5420

     

    Public Health-Rifle

    95 West 14th Street

    Rifle, CO 81650

    970-625-5200

     

    Public Health – Glenwood Springs 

    2014 Blake Avenue

    Glenwood Springs, CO 81601 

    970-645-6614

     

    Clear Creek County Public Health

    1531 Colorado Blvd. (Comm. Res. Ctr)

    Idaho Springs, CO 80452

    303-567-3147

     

    Eagle County Public Health 

    100 W. Beaver Creek Blvd. 

    Avon, CO 81620

    970-949-7026

     

    Eagle County

    20 Eagle County Road, Suite E

    El Jebel, CO 81623

    970-704-2760

  • Help is also available through the sources below

  • CRISIS LINES:

    AIDS hotline…………………..1-800-342-2437

    Suicide hotlines………………1-800-784-2433, 1-800-SUICIDE, 1-800-273-8255

     

    SUPPORT GROUPS:

    Alcoholics Anonymous……...(970) 928-0499

    Al-anon/Alateen…………………1-888-966-4662

    Narcotics Anonymous……….1-800-912-4597

  • Infectious Disease Medical Screen

  • INFECTIOUS DISEASE MEDICAL AND BEHAVIORAL SCREENING

    In response to increasing rates of hepatitis B and C, sexually transmitted diseases, TB and HIV, all clients/patients receiving services from substance abuse treatment providers licensed by theAlcohol and Drug Abuse Division (ADAD) shall be screened for past and present risk factors, including those associated with substance abuse, for disease acquisition and transmission. In a joint effort, ADAD, the Colorado Department of Public Health and Environment, substance abuse treatment providers and HIV and hepatitis advocacy groups and coalitions have developed twoScreens for determining client/patient risk. In introducing the Screens to clients/patients the following points should be made (not in preferential order):Administering a screen is required by state regulation;

    • Privacy of responses to screen questions is protected by federal regulation and state law;
    • The screen provides important information to clients/patients about their levels of risk;
    • In order to get the best information, honest, accurate responses to questions are vital.

  • INFECTIOUS DISEASE MEDICAL SCREEN

    The Infectious Disease Medical Screen is intended to be self-administered at time of intake or shortly thereafter. A counselor or other person knowledgeable about the Screen should be available to assist with any client/patient questions or concerns.

    Questions 1 through 8 screens for risk of hepatitis B and/or C exposure. Questions 9 through 14 screens for risk of tuberculosis exposure/infection.

    Appropriate Clinical Responses Guide

    A “Yes” response to any of questions 1 through 7 and no record of being tested for hepatitis B and C should prompt a referral for testing and appropriate follow-up.

    A “Yes” response to question 8 should prompt making information available about the possible (though low-level) risks involved.

    If any of the categories in question 9 are marked, a TB skin test should be encouraged.

    A “Yes” response to any of questions 10 through 14 indicates a high risk for active TB or TB infection and a referral to a healthcare practitioner or health department for testing/treatment should be made immediately.

  • I understand that my responses to this screen are protected under the federal regulations governing Confidentiality

    Of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that HIV, STD and TB related information about me is protected by state law and cannot be disclosed unless state law authorizes the disclosure.

    I have read and understand the above.

  • 1. Have you been a recipient of a blood transfusion or organ transplant prior to 1992 (includes receiving blood during birth or other surgical procedures)?*
  • 2. Have you ever been or are you now on long-term hemodialysis (blood cleansing)?*
  • 3. Are you a recipient of clotting factor made prior to 1987?*
  • 4. Have you ever been stuck by a needle or anything sharp that was likely to have been contaminated with hepatitis C infected blood?*
  • 5. Were you born to a mother who had hepatitis?*
  • 6. Have you ever had symptoms of liver disease or abnormal liver function/enzyme tests?*
  • 7. Have any of your sexual partners been infected with hepatitis B or C?*
  • 8. Have you been the recipient of tattooing or piercing in unsanitary conditions (unsterile needles)?*
  • 9. Mark all of the following that currently apply to you or that applied to you in the past.*
  • 10. Have you had a cough for more than three weeks?*
  • 11. Have you coughed up blood/colored mucous?*
  • 12. Do you have swollen, non-tender lymph nodes?*
  • 13. Have you had a prolonged loss of appetite or unexplained weight loss of ten pounds or more?*
  • 14. Have you had recurrent fevers or heavy night sweats for more than three weeks?*

  • Response Guide

    * If you answered “yes” to any question # 1-7, please see your counselor for a referral to be screened for hepatitis B and C.

    * If you answered “yes” to question # 8, please see your counselor for a referral for infectious disease screening and testing.

    * If you answered “yes” to any of the categories in question # 9, please see your counselor for a referral to be screened for TB.

    * If you answered “yes” to any question # 10-14, please see your counselor immediately for a referral TB screen and treatment

  • Recovery Resources Resilience Survey

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