Repeat Offender Education Program Registration Form
Thank you for filling out the information below for the Repeat Offender Education Program at Texas Counseling & Education. Class Schedule: Saturday or Sunday 1pm-4pmMeets in person the first and the last class. This is a 10 week class meeting every Saturday or Sunday from 1pm-4pm. There is a $50 charge to make up one missed class. Payment plans are okay but must pay at least $50 each class. Can attend on zoom after the first class. The first class and last class MUST be attended in person. Must stay on camera during entire class to receive certificate. Must stay in one spot and focus your attention to the class. Absolutely no driving or riding in any moving car. All comments and discussions should be respectful towards each other and stay in group. Be mindful of background noise and distractions as much as possible. You will be discharged unsuccessfully if not following guidelines. Please text office at 262-434-0076 if you do not have email for zoom at 12:30pm on Sunday. Please check spam first. Certificates need to be picked up in 10 days of class completion. If you are not familiar with zooms basic features, please attend class in person.
Name
First Name
Last Name
What is your middle name?
What is your birthdate?
-
Month
-
Day
Year
Date
Which class do you want to register for?
November 16- January 18 is full
January 10- March 14
January 25- March 29
April 5
E-mail
example@example.com
Mobile Number
Probation Officer Name
First Name
Last Name
Probation Officer Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you had a substance abuse evaluation with us before? Please type yes or no.
What is your driver's license number?
This class requires everyone to attend at least two 12 step meetings. This includes AA, NA, CA, Dharma Recovery, Celebrate Recovery, Overcomers, Smart Recovery, etc. Have you been to a meeting before?
How many dependents live in your home?
How many years of schooling have you completed?
Highest grade of schooling completed?
How much time were you unemployed in the past three years?
List all the jobs you have held in the last three years, beginning with your present job?
Gender
Ethnicity
Marital Status
What county were you arrested in second or more DWI?
What's your case number?
How many times have you been arrested?
List all arrests, charges and the date:
What's your sobriety date?
How many times has your license been suspended or revoked?
Your age when began drinking or drugging?
This class is ten weeks long. You must complete all 10 days in the same session. There is a $50 charge for missed class and only allowed to miss two classes. Classes must be completed during make up sessions if missed. please write YES below in the box to show you understand.
Submit
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