• DWI EDUCATION CLASS (3 SESSIONS /12 HOURS) - INSTRUCTIONS

  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have a driver license?

  • PERSONAL DATA FORM

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • (In case we cannot reach you)
  • Do you feel your drinking or drugging has contributed to family problems at any time in your life? Circle one:*

  • EDUCATION

  • Highest school grade completed: (Pick one)*
  • Are you employed in the type of work you've been trained to do at this time?*

  • DEMOGRAPHIC

  • SEX*
  • ETHNICITY*
  • MARTIAL STATUS*

  • ARREST INFORMATION

  • Prior to this arrest, was your license...*

  • Your age when you...

  • Dates of current and previous arrest and charges:

  • Rows

  • OTHER INFORMATION

  • Have you ever thought you might have a drinking problem?*
  • Have you ever received help from ...(choose all that apply)*
  • Where do you usually drink?*

  • 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 hereby authorize such use, with the further understanding that this information will otherwise be held confidential and not released to other individuals for any reason without my signed consent.

  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • PAGE #4

  • CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION

  • I, {fullName}, authorize DWI - Education Express to disclose to C.S.O/Referral Sourse the following information: DWI Education Related.

    The purpose of the disclosure authorized in this is to:
    Coordinate Services

    I understand that all Offender Education Programs shall abide by and obtain any consent to disclosure required by applicable 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 action has been taken in response to it, and that in any event, this consent expires automatically as follows.

    1 year after the date shown below

    (specification of the date, event, or condition upon which this consent expires)

  • VIDEOCONFERENCE SESSIONS CONSENT FORM

  • Addendum to Consent form

  • With this form I am choosing to attend via electronic medium through the internet including but not limited to videoconferencing the program sessions I am enrolled with A.C.E.S. (Affordable Counseling & Educational Services) (DBA of SUNRISE BEHAVIORAL ASSOCIATES LLC).

  • By choosing this option, I understand that:
    • This consent form is in addition to any other consent forms signed. All consent forms remain in effect
    • Participation in electronic meetings is voluntary.
    • Videoconferencing is an online communication tool allowing for face-to-face video, voice, or text-based chat dialogue.
    • Client software/app, currently Zoom, must be downloaded onto a computer/cell phone/other electronic device. Another service may be substituted as determined by ACES.
    • A Basic/Personal meeting account must be opened to use this service, i.e. https://www.zoom.us.
    • You agree to be online at least five minutes prior to each session, alone, in quiet room, door closed. Background noise interferes withparticipant's ability to hear. No observers are allowed due to privacy of other participants.
    • Services are paid at the same rate as in person visits.
    • All Program rules covered inthe previously signed Consent form applies. This includes the $20 NO-SHOW fee for any missed appointment as explained to you during your intake/registration.
    • Zoom offers secure communications, however, any internet based communication is not guaranteed to be 100%secure/confidential. I am willing to take this risk and also agree that ACES will not be held responsible if any outside party breaches access to my personal or confidential information.
    • Confidentiality should be treated like an in-office session: no outside distractions, turn off cell phones, close other programs on computer and "arrive" on time.
    • Technical problems could occur. If the video call is disrupted, please contact us at 713-858-1543 to help you. If reconnection cannot occur, the session will be rescheduled.
    • Failure to abide by the rules will result in no credit being issued for the meeting.
  •  
  • Should be Empty: