SAP Form
SAP Client Intake Form
Client Information
Full Name
First Name
Last Name
ID Number
Date Of Birth
-
Month
-
Day
Year
Date
Social Security Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Who referred you to this SAP evaluation?
Employer
Self
Court/Legal
Other
Reason for SAP Referral
Nature of Violation/Incident
Alcohol-related
Drug-related
Both
Other
Date of Violation
-
Month
-
Day
Year
Date
Results:
Positive
Refusal To Test
Other
Have you previously undergone an SAP evaluation?
YES
NO
If yes, please provide the SAP’s full name and contact information:
Our referred SAPs do their evaluation, via video calls. Do you understand?
*
YES
NO
Other
Is your position classified as DOT safety-sensitive Employer?
YES
NO
Choose the DOT Agency of employment
Federal Motor Carrier Safety Administration (FMCSA)
Federal Railroad Administration (FRA)
Federal Transit Administration (FTA)
Federal Aviation Administration (FAA)
The United States Coast Guard (USCG)
Pipeline and Hazardous Materials Safety Administration (PHMSA)
Are you currently employed?
YES
NO
Employer Name
Supervisor/ Manager Name
Supervisor/ Manager Number
Upload CDL ID
Browse Files
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Do you understand that this information will be given to the Substance Abuse Professional (SAP) as a requirement and will be handled confidentially?
YES
NO
Did you assign Chantei McPherson to be your designated SAP?
YES
NO
Please sign below
Continue
Continue
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