DWIE Registration Form

Thank you for filling out the registration form for the DWI class with Texas Counseling and Education. Payment must be made within 24 hours or will be discharged. WILL BE DISCHARGED IF PAYMENT IS NOT MADE.

Class Schedule:

●       Friday: 6:00 PM - 10:00 PM

●       Saturday & Sunday: 9:00 AM - 1:00 PM

Important Information:

●       Pretest & Postest: Both the pretests and postest must be completed before your certificate can be issued.

● Class has a limited capacity, if the class you have chosen is full, you will be placed in the next available class.

Attendance & Participation Guidelines:

●       Stay on Camera: You must stay on camera throughout class and attend all 3 days in order to receive your certificate.

●       Stay in One Spot: Remain in one spot, focused on the class. No driving or riding in a car during class, and you must be alone and in a stationary location the entire time. NO DRVING OR RIDING IN THE CAR. You must be alone and in one spot.

●       Respectful Behavior: All comments and discussions should remain respectful towards each other.

●       Minimize Distractions: Be mindful of background noise and distractions.

Zoom Link:

●       The Zoom link will be sent on Friday at 5:00 PM. Class starts at 6:00pm. Will not be allowed to enter if more than 10 minutes late.

●       If you do not receive the link by 5:30 PM on the first day of class, please text 262-434-0076 (check your spam folder first).

Payment:

●       $80 Payment is due within 24 hours of registration.

●       You will receive an email with a payment link after booking.

If you are not familiar with Zoom's basic features, you may attend the class in person instead.

Notice:
You have 15 days to collect your certificate after the class is completed.
What date would you like to register for? There is a limit of 30 people for class. If the class is not full yet, you can join. Please call our office to make sure you can join the class listed below.

Texas Counseling and Education

Personal Data Form DWI 262-434-0076
Name

First NameLast Name
Middle Name
Middle Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Probation Officer's name:
Probation Officer's email:
How many dependents, other than yourself live with you? Adults?type here Children?blank
Do you feel your drinking or drugging has contributed to family problems at any time in your life?
If yes,why?
Education
How many years of schooling have you completed?
Highest school grade completed: (click one)
Employment

List all the 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
Most Current Job
Past Job
Past Job
How much total time were you unemployed in the last 3 years?
Demographic
Gender
Ethnicity
Marital Status
Arresting Information
Have you been to court yet for this charge?
Prior to this arrest, was you license…..
If Suspended or Revoked:
Your age when you
Dates of current and previous arrest and charges:
Have you ever thought you might have a drinking problem?
Have you ever received help from: (click all that apply)

Other
If Other please explain:
Where do you usually drink?: (click all that apply)

Other
I understand that information about me and my progress in the DWI school will be used for research purposes and will be shared with Probation and do here by authorize such use with the further understanding that this information will otherwise be help confidential and not released to other individuals for any reason without my consent.

Sign Here

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION
I, First & Last Name authorize Texas Counseling and Education to disclose to Community Supervision and Corrections.

The purpose of the disclosure authorized in this is to:

Inform the following information: Attendance, participation, evaluation and referral

I understand that all Offender Education Programs shall abide by an obtain any consent to disclosure required by application 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 actions have been taken in response to it, and that in any event, this consent expires automatically as follows.
Date

MonthDayYear
Date
Signature

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION
I, First & Last Name authorize Texas Counseling and Education to disclose to Texas Department of License and Regulations.

The purpose of the disclosure authorized in this is to:

Inform the following information: Attendance, participation, evaluation and referral

I understand that all Offender Education Programs shall abide by an obtain any consent to disclosure required by application 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 actions have been taken in response to it, and that in any event, this consent expires automatically as follows.
Date

MonthDayYear
Date
Signature

TEXAS COUNSELING

DWI EDUCATION PROGRAM

Notice for unsuccessful discharges from DWIE

If for any reason you are discharged unsuccessfully from the DWIE PROGRAM. You may attend one of the next two scheduled DWIE classes and pay only $40 to attend. If you do not return for one of the next two scheduled DWIE classes you will be required to pay the full amount of $80 upon admission to the DWIE class.

If you exhibit behaviors deemed inappropriate or hostile you will not be allowed to return to the Texas Counseling and Education program and there will be no refunds.
Signature
Date

MonthDayYear
Date

WHAT IT COST ME

In order to determine cost of DWI, will you please answer these questions to the best of your knowledge at this time?
My costs are:
ATTORNEY’S FEES
FINES AND COURT COSTS
LOSS OF SALARY
BOND
CAR COSTS (IF CRASH INVOLVED)
CAR DAMAGE REPAIRS
TOWING AND STORAGE
TEMPORARY TRANSPORTATION
BUS, CAB
RENTAL/LEASE CAR, ETC.
DWI EDUCATION COURSE FEES
ALCOHOL/DRUG PROGRAMS/ COUNSELING/ TREATMENT
INCREASED COST OF INSURANCE PER YEAR
PROBATION FEES
ANY OTHER COSTS
TOTAL
This class is 3 consecutive days. You must complete all 3 days in the same session. You must be on zoom or in office on Saturday and Sunday at 9am also. Please write YES below in the box to show you understand.
Will you be attending in office or on zoom? Please write below office or zoom. If you do not have a link by 5:30pm after checking spam, please text 262-434-0076.
Should be Empty:

Texas Counseling and Education

Education

Employment

Demographic

Arresting Information

TEXAS COUNSELING

DWI EDUCATION PROGRAM

Notice for unsuccessful discharges from DWIE

If you exhibit behaviors deemed inappropriate or hostile you will not be allowed to return to the Texas Counseling and Education program and there will be no refunds.

BD- l

My Personal Action Plan

WHAT IT COST ME

My costs are: