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DWI Intervention BD-1
Brian Knaack
2022-08-29T09:52:02-05:00
DWI Intervention BD-1
Fill out this form prior to the first day of the course.
What happened during your arrest?
"
*
" indicates required fields
Name
*
First
Middle Initial
Last
Email
*
What is the reason you were stopped?
*
Speeding
Driving too slow
Light(s) not working
Had a wreck
Other Moving violation
Other
Before my arrest, I was:
*
Check all that apply.
Drinking alcohol after work
Engaged in a recreational activity while using alcohol (or drugs), i.e. ball game, party, work function, etc.
Coping with problems (relationship, work, family, etc.)
Other
I had been using:
*
Check all that apply.
Beer
Wine
Liquor
Marijuana
Opiates
Pills
Methamphetamines
Other
I was with:
*
Check all that apply.
Spouse
Friend(s)
Co-workers
Family
Stranger/Other
Alone
Do you feel your drinking or drugging has contributed to family problems at any time in your life?
*
Yes
No
Why do you feel that drinking or drugging has contributed to family problems?
*
What was your age when you began drug activities?
*
What was your age when you were arrested for your first drug-related offense?
*
What was your age when you began drinking alcohol?
*
What was your age when you were arrested for first alcohol-related offense?
*
Have you ever received help from the following?
*
Check all that apply
Family doctor
Psychologist or psychiatrist
Church
Relative or friend
Narcotics Anonymous
Alcoholics Anonymous
Drug or alcohol rehab program
None of the above
Summarize any other comments about your alcohol/drug usage and the events leading up to your arrest.
Optional
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