Alcohol Drug Evaluation Form

State of Offense / Jurisdiction

Type of Offense

Attorney Name (If applicable)

Attorney Phone

Attorney Email

Probation / Parole Officer Name

Probation / Parole Officer Email

County / Parish of Offense

Option A: Standard Full Evaluation ($265)Option B: Expedited Full Evaluation ($310 - Completed within 72 hours)Option C: Basic Screening Only ($100)

(Note: A 2.99% online credit card processing fee will be applied to all transactions at checkout.)

WARNING: BASIC SCREENING REJECTION WAIVER

I understand that I have selected a Basic Screening, which is NOT a full comprehensive evaluation. I acknowledge that most courts, DMVs, and probation departments will not accept a Basic Screening as fulfillment for a court-mandated evaluation. I am choosing this option at my own risk. I understand and agree that NO REFUNDS will be provided under any circumstances if this Basic Screening is rejected by my jurisdiction.

I have read the warning above and agree to the No-Refund policy for the Basic Screening.

MAST (Michigan Alcohol Screening Test)

Rows	Yes	No	N/A
Do you enjoy a drink now and then?
Do you feel you are a normal drinker? (“normal” – drink as much or less than most other people)
Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening?
Does your wife, husband, a parent, or other near relative ever worry or complain about your drinking?
Can you stop drinking without a struggle after one or two drinks?
Do you feel guilt about your drinking?
Do friends or relatives think you are a normal drinker?
Are you able to stop drinking when you want to?
Have you ever attended a meeting of Alcoholics Anonymous?
Have you gotten into physical fights when drinking?
Has your drinking ever created problems between you and your wife, husband, a parent, or other relatives?
Has your wife, husband (or other family members) ever gone to anyone for help about your drinking?
Have you ever lost friends because of your drinking?
Have you ever gotten into trouble at work because of your drinking?
Have you ever lost a job because of your drinking?
Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking?
Do you drink before noon fairly often?
Have you ever been told you have liver trouble? Cirrhosis?
After heavy drinking, have you ever had Delirium Tremens (D.T.’s) or sever shaking, or heard voices, or seen things that weren’t there? How many times? __*
Have you ever gone to anyone for help about your drinking?
Have you ever been in a hospital because of drinking?
Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital where drinking was a part of the problem that resulted in hospitalization?
Have you ever been seen at a psychiatric or mental health clinic or gone to any doctor, social worker, or clergyman for help because of any emotional problem, where drinking was part of the problem?
Have you ever been arrested for drunk driving, driving while intoxicated, or driving under the influence of alcoholic beverages or drugs? How many times? __*
Have you ever been arrested, or taken into custody, even for a few hours, because of other drunk behavior? How many times? __**

DAST (Drug Abuse Screening Test)

Rows	Yes	No	N/A
CleanlinessHave you used drugs other than those required for medical reasons?
ResponsivenessDo you abuse more than one drug at a time?
FriendlinessAre you always able to stop using drugs when you want to?
Have you had "blackouts" or "flashbacks" as a result of drug use?
Do you ever feel bad or guilty about your drug use?
Does your spouse (or parents) ever complain about your involvement with drugs?
Have you neglected your family because of your use of drugs?
Have you neglected your family because of your use of drugs?
Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)?

CAGE & CAGE - AID

Rows	Yes	No	N/A
Have you ever felt you ought to cut down on your drinking or drug use?
Have people annoyed you by criticizing your drinking or drug use?
Have you ever felt bad or guilty about your drinking or drug use?
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?

AUDIT (Alcohol Use Disorder Identification Test)

Rows	0	1	2	3	4
How often do you have a drink containing alcohol? (0=Never, 1=Monthly or less, 2=2-4 times a month, 3=2-3 times a week, 4=4 or more times a week)
How many drinks containing alcohol do you have on a typical day when you are drinking? (0=1 or 2, 1=3 or 4, 2=5 or 6, 3=7 to 9, 4=10 or more)
How often do you have six or more drinks on one occasion? (0=Never, 1=Less than monthly, 2=Monthly, 3=Weekly, 4=Daily or almost daily)
How often during the last year have you found that you were not able to stop drinking once you had started? (0=Never, 1=Less than monthly, 2=Monthly, 3=Weekly, 4=Daily or almost daily)
How often during the last year have you failed to do what was normally expected from you because of drinking? (0=Never, 1=Less than monthly, 2=Monthly, 3=Weekly, 4=Daily or almost daily)
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? (0=Never, 1=Less than monthly, 2=Monthly, 3=Weekly, 4=Daily or almost daily)
How often during the last year have you had a feeling of guilt or remorse after drinking? (0=Never, 1=Less than monthly, 2=Monthly, 3=Weekly, 4=Daily or almost daily)
How often during the last year have you been unable to remember what happened the night before because you had been drinking? (0=Never, 1=Less than monthly, 2=Monthly, 3=Weekly, 4=Daily or almost daily)
Have you or someone else been injured as a result of your drinking? (0=No, 2=Yes but not in the last year, 4=Yes during the last year)
Has a relative, friend, doctor, or other healthcare worker been concerned about your drinking or suggested you cut down? (0=No, 2=Yes but not in the last year, 4=Yes during the last year)

Medical Status: (Please describe your history of hospitalizations, chronic problems, and current physical health)

Employment and Support: (Please describe your education level, employment history, and current financial support)

Drug and Alcohol Use: (Please list your history of use, frequency, and periods of abstinence)

Legal Status: (Please list past arrests, convictions, current charges, and probation/parole status)

Family History: (Is there a family history of psychological or substance use issues?)

Family and Social Relationships: (Please describe your marital status, living arrangements, and satisfaction with relationships)

Psychiatric Status: (Please describe any history of psychiatric treatment, depression, anxiety, or suicidal ideation)

Upload Driver's License / State ID

Upload Arrest Report / Incident Ticket

Upload proof of resident address

I, [#first_3, #last_3], hereby authorize Dr. Steven Gonzalez, a Licensed Chemical Dependency Counselor (LCDC), to conduct the MAST, DAST, AUDIT, ASI and CAGE screening assessment for the purpose of evaluating and addressing substance abuse concerns. I understand and I agree to the following terms:

Purpose of Evaluation: I consent to the MAST, DAST, AUDIT, ASI and CAGE assessment conducted by Dr. Steven Gonzalez to gain insights into potential substance abuse issues and to support relevant counseling or treatment.

Confidentiality: I understand that the information obtained during the MAST, DAST, AUDIT, ASI and CAGE assessment will be treated confidentially and will only be disclosed to individuals directly involved in the assessment and subsequent counseling or treatment.
Sharing of Results: I authorize Dr. Steven Gonzalez to share the results of the MAST, DAST, AUDIT, ASI and CAGE assessment with my attorney/Company, [#input_32], for the purpose of legal proceedings or review related to my application.

Limits of Confidentiality: I acknowledge that there may be legal and ethical limits to confidentiality, and Dr. Steven Gonzalez will adhere to these limits as required by law.

Voluntary Participation: I understand that participation in the MAST, DAST, AUDIT, ASI and CAGE assessment is voluntary, and I have the right to withdraw my consent at any time without affecting my current or future treatment.

Storage of Information: I consent to the storage of the assessment results in a secure manner by Dr. Steven Gonzalez for the duration required for assessment, counseling, and treatment purposes.

Access to Information: I understand that I have the right to access the information collected during the MAST, DAST, AUDIT, ASI and CAGE assessment and may request a copy of the assessment results.

Questions and Clarifications: I have had the opportunity to ask questions and seek clarification regarding the MAST, DAST, AUDIT, ASI and CAGE assessment, and any concerns have been addressed to my satisfaction.

By signing below, I acknowledge that I have read and understood the terms of this consent form, and I voluntarily consent to the MAST, DAST, AUDIT, ASI, and CAGE assessment conducted by Dr. Steven Gonzalez or a licensed Chemcial and Dependency Counselor supervised by him.

Signature*

Parent Guardian Signature (Optional)

My Products

Alcohol and Drug Screening (Generally Not Accepted for Court Mandated Evaluations)

$100.00 Quantity

Full Alcohol and Drug Evaluation

$265.00 Quantity

Expedited Alcohol and Drug Evaluation

$310.00 Quantity

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