On Call Advantage - Required Client Information
ADSS Information
Case / Docket Number
*
If applicable: 2nd Case / Docket Number
Personal Information
First Name
*
Middle Initial
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Contact Information
Street Address, City, State, Zip
*
If different: Mailing Address
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact
Emergency Contact Name (First & Last)
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Household Information
Marital Status
*
Single
Married
Divorced
Widowed
Dependents living with you
*
Dependents NOT living with you
*
Living Arrangement
*
Alone
With Roommates
With Significant Other
With Parents
Background Information
Primary Language
*
Please Select
English
Spanish
Russian
Vietnamese
Other
If Language is "other" what is it?
Interpreter requested?
*
Yes
No
Highest Level Education Level
*
Please Select
Less Than HS
High School / GED
Vocational
College Courses
AA/AS
BA/BS
Graduate Degree
Currently in School
Area of Study
Currently Employed?
*
Yes
No
Frequent Job Changes?
Yes
No
Type of Work
ONLY if you have: Oregon Drivers License Number
Leave blank if you do not have an Oregon Drivers License
Incident Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of Alleged Offense
SID Number
Found on Court Document - May not have one
Court Attended
*
Please Select
Lincoln County Circuit Court
Linn County Circuit Court
Florence Municipal Court
Junction City Municipal Court
Lebanon Municipal Court
Sweet Home Municipal Court
Brownsville Municipal Court
Linn County Justice Court
Charge
*
Alcohol Derived DUII
*
Yes
No
BAC Level
Alcohol Test Type
Please Select
Breath
Blood
Refused
UNKNOWN
Controlled Substance Involved?
*
Yes
No
List Substances
Alcohol is NOT a Controlled Substance.
Inhalant Involved
*
Yes
No
List Inhalants
Adjudication Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date the judge signed the court document
DUII Diversion
*
Yes
No
Diversion End Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
DUII Conviction
Yes
No
Total Number of DUIIs
*
1 if this is your first one
Have you been previously arrested for Alcohol and/or Drugs
*
Yes
No
If Yes, Give Arrest Details (Date, Location, Reason)
Have you attended any alcohol and/or drug treatment programs in the past?
*
Yes
No
If Yes, Give Treatment Details (Date, Location, Information)
File Name
Submission Path
Submit
Should be Empty: