DWI Intervention BD-1

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DWI Intervention BD-1Brian Knaack2022-08-29T09:52:02-05:00

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

Hidden

Course Date

MM slash DD slash YYYY

Title

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