Please provide all the required documentation. Please do not leave any blank spaces. All the information is kept in strict confidence and may not be disclosed without your permission.

Please answer all the following questions. All the information is kept in strict confidence and may not be disclosed without your permission. 

DIRECTIONS: The questions that follow are about your use of alcohol and other drugs. Your answers will be kept confidential. Mark the response that best fits you. Answer the question in terms of your experiences in the past 6 months.

During the past 6 months...

The next questions are about your Lifetime experiences.

Think of the 12 hours before your DUI arrest. Read the following questions and place a check next to the appropriate answer. For some questions you may have to check more than one answer. 

Answer True or False to the following questions by placing a check in the appropriate box. When completed, email form back to us OR print and bring a copy to enrollment appointment.

DUI program services in California must be completed through the Department of Health Care Services (DHCS) licensed DUI program. California’s Health and Safety Code (HSC), Division 10.5, Part 2, Chapter 9, Section 11836 establishes the DHCS as having the sole authority to license DUI Programs to provide alcohol or drug recovery services to a person whose license to drive has been administratively suspended or revoked for, or who is convicted of, a violation of Section 23152 or 23153 of the Vehicle Code (VC), and admitted to a program pursuant to Section 13352, 23538, 23542, 23548, 23552, 23556, 23562, or 23568 of the Vehicle Code.

Pursuant to Title 9, California Code of Regulations (CCR), Chapter 3, Section 9848, a DUI program may enroll any person who presents documentation from the court or the DMV verifying his/her arrest or conviction for a DUI violation specified in HSC Section 11836 as referenced above. To ensure timely program enrollment, DHCS will allow several types of documents generated by the DMV or court. (See DHCS acceptable Enrollment Document Matrix)

Although DHCS licenses DUI program services, program requirements are ultimately dependent on offenses specified in California Vehicle Code, and interpreted by the California Department of Motor Vehicles (DMV)-Mandatory Action Unit (MAU), in conjunction with the court of conviction.

When enrolling in a DUI program following arrest for a DUI offense prior to a conviction, the DUI program will enroll you in the most appropriate program type based on the information contained in the enrollment documents you present along with any additional information you are able to provide at that time. DHCS encourages you to contact the DMV-MAU at (916) 657-6525 if you have questions/concerns specific to the type of DUI program you will ultimately be required to complete.

Please note, following your initial DUI program enrollment there may be instances in which DMV’s MAU review of your DUI offense/driving history and/or court proceeding may necessitate a modification of the program type you are/were initially enrolled in. In all instances, you are financially responsible for all DUI program services received and/or incurred during your enrollment in a DUI program. (Additional program service fees are identified in the participant contract you will review and sign at the time of DUI program enrollment)

The following consent/agreement and required enrollment documents must be completed and placed in your participant file as required by CCR, Title 9 requirements. As with all documents produced during your DUI program enrollment and participation, you are encouraged to retain copies for your records.

*I verify I have read and understand the information provided to me on the Informed Consent and Agreement document regarding my DUI program enrollment. I am aware in some instances the DMV- MAU or court may later amend my program service type and in all cases, I am financially responsible for all DUI program services received.

I hereby authorize Jackson-Bibby Awareness Group to disclose information and records pertaining to my participation in the program to the following:

The Department of Motor Vehicles.
The Department of Healthcare Services.
The County Offices of Alcohol and Drug Abuse Services.
The appropriate branches of the Judicial System.
My personal attorney.
My personal physician.

The disclosure of information and/or records herein authorized is required for the purpose of establishing or determining my status, progress, and/or compliance with the terms and conditions of my participation in the program. Such disclosure shall be limited to information and/or records in regard to my progress and participation in the program.

I understand that this authorization can be revoked by the undersigned at any time except to the extent that action has been taken in reliance thereon. If not earlier revoked, it shall terminate ninety (90) days after my participation in the program has ended. I also understand that despite the codes (California Civil Codes 56.11 and 56.15, and Federal Regulation CFR Section 2.31), confidential information and/or records may be disclosed without my authorization pursuant to state and federal law in the following circumstances:

Pursuant to a proper subpoena or court order.
Reporting child abuse or elder abuse.
Reporting an individual who is a danger to him/herself or a third party.
Reporting the intent to commit a crime on program premises or against program staff.
A photocopy, facsimile or duplicate copy of this authorization shall be as valid as the original.

I also hereby authorize Jackson-Bibby Awareness Group , to disclose information to my designated representative:

Dear Client,

IT SHOULD BE UNDERSTOOD THAT THESE RULES AND REGULATIONS GOVERNING THIS CONTRACT ARE SET FORTH BY THE COUNTY OF SAN BERNARDINO, DEPARTMENT OF BEHAVIORAL HEALTH-ALCOHOL AND DRUG SERVICES, AND BY THE STATE OF CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES.  “PROGRAM’S” ROLE IS TO ASSURE THAT EACH PARTICIPANT ADHERES TO THE REQUIREMENTS AS SET FORTH.  THE PARTICIPANT AGREES TO ABIDE BY SAID RULES.

We are pleased to provide Virtual Services as an alternative to attending a DUI program in-person. Please note that both in-person and virtual services are both available to attend. A participant can select to do just Virtual services, in-person, or a hybrid combination of both. A participant can change between types of services during your program to accommodate your schedule.

PROGRAM RULES/PARTICIPANT RESPONSIBILITY

Virtual Services will enable you to attend your DUI classes with a certified counselor via the Zoom virtual meeting platform. To participate in Virtual Services, you must:

•  Sign the Virtual Services Letter and return it to Jackson-Bibby Awareness Group Inc. to the email based on your location:

Redlands:   redlands.admin@jacksonbibby.com

Victorville:   victorville.admin@jacksonbibby.com

• Register in advance for the session via an email link that will be sent to you in advance of the scheduled session.

• To receive credit for the session, you must:

· Register with your full name as provided to us at Enrollment. Credit will not be given if any aliases or other screen names are input into Zoom.

· Make sure you have paid for your virtual session in advance. Payment of credit card or debit card is only accepted at this time and payments can be made over the phone in advance.

· Be In the virtual meeting at the provided start time. It is recommended that arrive at least 10 minutes early so that you can make sure the program is downloaded and all speakers and microphones are working.

· Attend the session in a private room, free of distractions.

· Stay for the entire session and participate when called upon.

· If you attempt join the Zoom room after the scheduled start time, you will not be allowed in and you will be marked as absent.

CONNECTIVITY/ATTENDANCE

If you have issues with connectivity or attending, please contact the office that you are enrolled at by either phone or email. Their info is as follows

Redlands:   redlands.admin@jacksonbibby.com / Phone (909) 792-6925

Victorville:   victorville.admin@jacksonbibby.com / Phone (760) 241-3300

Certain technology is required to participate in this program. You must have either a computer, tablet, or phone with a working microphone, speakers, and a camera (for video meetings). You must also be able to download the free Zoom software onto a computer or download the Zoom application on a tablet or phone.

You are responsible for having working devices and a reliable connection to Zoom through the internet or cellular service. If you are disconnected, please re-enter the Zoom meeting as soon as possible. If you cannot immediately rejoin, you will need to send the office an email describing why you were disconnected. If you are not able to rejoin right away, you will not be given credit for the class. A leave of absence may be given if you can provide documentation showing that you lost service through both internet and cellular during the time of your group. A leave of absence fee will apply. If you cannot provide documentation or do not rejoin the group immediately, you will be marked as absent, and an absence fee will apply.

PROGRAM SOBRIETY/ABSTINENCE

All Program participants must comply with the Program sobriety regulations as defined in Subsection 9874 of Title 9 of the California Code of Regulations.

This is up to the counselor’s and administrators’ discretion. This includes but is not limited to: a participant abnormally slurring of speech; visual evidence of the participant ingesting drugs or alcohol; and a participant admitting that they are currently under the influence of drugs or alcohol. If you are determined to be under the influence, you will not be given credit for the session and will be subject to termination from the program.

The DUI program shall determine whether the participant is under the influence of drugs or alcohol by either:  requiring the participant to submit to testing with a chemical device designed to determine if an individual is under the influence or if two or more staff members documenting the behavior in the participant’s program record. Title 9 Section 9874 (c) (2).

If the DUI program determines that the participant is under the influence of drugs or alcohol, the DUI program shall advise the participant that he/she may obtain a drug test at his/her own expense in order to refute the determination of being under the influence of drugs. Title 9 Section 9874 (e) (1). If the participant chooses to obtain a drug screening, it must be conducted by a clinical laboratory licensed by the Department of Health Services and must be conducted within 24 hours of the DUI program determination that participant was under the influence.        

TERMINATION FOR PROGRAM NON-COMPLIANCE

A participant shall be terminated and referred back to the sentencing Court/Probation for the reasons outlined in your contract. In addition, a participant shall be terminated for failure to comply with the policies and procedures outlined in this Virtual Services Agreement.

AGREEMENT

Please read the privacy policy on the next page and sign where indicated. Return the signed page via email the email option listed above.  If you have any questions, please email or contact your program location’s manager. This Virtual Services Agreement does not override the contract you have signed, it only supplements the rules and regulations.

I have read and agree to Jackson-Bibby Awareness Group, Inc’s Virtual Services Agreement & Policy.

Jackson-Bibby Awareness Group, Inc. will provide Virtual Services utilizing the Zoom Virtual Meeting Platform. To participate in Zoom meetings, you must read and agree to Zoom’s Privacy Policy.

Jackson-Bibby Awareness Group, Inc will continue to maintain confidentiality as stated in our Confidentiality Policy. Client’s will also be held to the Confidentiality Agreement signed upon enrollment.

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1) Risk of using email/texting

a) The transmission of client information by email and/or texting has a number of risks that clients should consider prior to the use of email and/or texting. These include, but are not limited to, the following risks:

b) Email and texts can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.

c) Email and text senders can easily misaddress an email or text and send the information to an undesired recipient.

d) Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted his or her copy.

e) Employers and on-line services have a right to inspect emails sent through their company systems.

f)Emails and texts can be intercepted, altered, forwarded or used without authorization ordetection.

g) Email and texts can be used as evidence in court.

h) Emails and texts may not be secure and therefore it is possible that the confidentiality of such communications may be breached by a third party.

2) Conditions for the use of email and texts The provider cannot guarantee but will use reasonable means to maintain security and confidentiality of email and text information sent and received. The provider is not liable for improper disclosure of confidential information that is not caused by provider intentional misconduct. Clients must acknowledge and consent to the following conditions:

a) Email and texting is not appropriate for urgent or emergency situations. Provider cannot guarantee that any particular email and/or text will be read and responded to within any particular period of time.

b) Email and texts should be concise. The client should call and/or schedule an appointment to discuss complex and/or sensitive situations.

c) All email can be printed and filed into the client’s record. Texts may be printed and filed as well.

d) Provider will not forward client’s identifiable emails and/or texts without the client’s written consent, except as authorized by law.

e) Clients should not use email or texts for communication of sensitive medical information.

f)Provider is not liable for breaches of confidentiality caused by the client or any third party.

g) It is the client’s responsibility to follow up and/or schedule an appointment if warranted.

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of email and/or texts between Jackson-Bibby Awareness Group, Inc (provider) and me, and consent to the conditions and instructions outlined, as well as any other instructions that the provider may impose to communicate with me by email or text.

On submitting the form, the form(s) will be emailed directly to Jackson-Bibby and a representative from Jackson-Bibby will reach out to schedule your enrollment appointment if it hasn't been scheduled already. 

At the time of your enrollment, the enrollment coordinator will review these documents with you and they will require you to sign and date them. If you have any further questions or have additional documents to submit, please contact the office that you are at enrolling at.

Redlands: redlands.admin@jacksonbibby.com / 909-792-6925

Victorville: victorville.admin@jacksonbibby.com / 760-241-3300

Barstow: barstow.admin@jacksonbibby.com / 760-256-6114