DWIE Registration Form Logo

  • Thank you for filling out the registration from for the DWI class with Texas Counseling and Education. After submitting this form please call the office to enroll in the class. 262-434-0076

     

    Class Schedule:

    ●       Friday: 6:00 PM - 10:00 PM

    ●       Saturday & Sunday: 9:00 AM - 1:00 PM

    Important Information:

    ●       Pretest & Posttest: Both the pretest and posttest must be completed before your certificate can be issued.

     Attendance & Participation Guidelines:

    ●       Stay on Camera: You must stay on camera throughout class and attend all 3 days in order to receive your certificate.

    ●       Stay in One Spot: Remain in one spot, focused on the class. No driving or riding in a car during class, and you must be alone and in a stationary location the entire time. NO DRVING OR RIDING IN THE CAR. You must be alone and in one spot.

    ●       Respectful Behavior: All comments and discussions should remain respectful towards each other.

    ●       Minimize Distractions: Be mindful of background noise and distractions.

    Zoom Link:

    ●       The Zoom link will be sent on Friday at 5:00 PM. Class starts at 6:00pm. Will not be allowed to enter if more than 10 minutes late.

    ●       If you do not receive the link by 5:30 PM on the first day of class, please text 262-434-0076 (check your spam folder first). 

    Payment:

    ●       $80 Payment is due by the first day of class.

    ●       You will receive an email with a payment link after booking.

     

    If you are not familiar with Zoom's basic features, you may attend the class in person instead.

    Notice:
    You have 15 days to collect your certificate after the class is completed.

  • Texas Counseling and Education

    Personal Data Form DWI 262-434-0076


  • How many dependents, other than yourself live with you? Adults? Children?

  • Education

  • Employment

    List all the jobs you have held in the past 3 years, beginning with your present job. Give a description of the type of job, year of employment, and reason for leaving

  • Demographic

  • Arresting Information

  • Clear

  • CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION

     

  • I, authorize Texas Counseling and Education to disclose to Community Supervision and Corrections.

    The purpose of the disclosure authorized in this is to:
     
    Inform the following information: Attendance, participation, evaluation and referral

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

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  • Clear

  • CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION

     

  • I, authorize Texas Counseling and Education to disclose to Texas Department of License and Regulations.

    The purpose of the disclosure authorized in this is to:
     
    Inform the following information: Attendance, participation, evaluation and referral

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

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  • Clear

  • TEXAS COUNSELING

    DWI EDUCATION PROGRAM

     

    Notice for unsuccessful discharges from DWIE

     

    If for any reason you are discharged unsuccessfully from the DWIE PROGRAM. You may attend one of the next two scheduled DWIE classes and pay only $40 to attend. If you do not return for one of the next two scheduled DWIE classes you will be required to pay the full amount of $80 upon admission to the DWIE class.

    If you exhibit behaviors deemed inappropriate or hostile you will not be allowed to return to the Texas Counseling and Education program and there will be no refunds.   

  • Clear
  •  - -

  • BD- l

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  • Before my arrest I was
                      etc)
           

  • During the week days, I tend to drink on (place number of drinks/ amounts of drugs used next to am/pm):

  • During the week-ends, I tend to drink (or use drugs) on (place number of drinks/ amounts of drugs used next to am/pm):

  • My Personal Action Plan

    BD- ll

  • WHAT IT COST ME 

    In order to determine cost of DWI, will you please answer these questions to the best of your knowledge at this time?

  • My costs are:

  • Should be Empty: