SAN ANTONIO COUNCIL ON ALCOHOL AND DRUG AWARENESS

DWI COURSE REGISTRATION

PRE TEST SCORE: __________
PERSONAL DATA FORM POST TEST SCORE: __________
MUST BE FILLED OUT COMPLETELY!
NDP SCORE: __________
CERT#: _________________________
DATE ___________________________

Last Name: ____________________________ First Name: ______________________ MI: _______

Drivers License Number ______________________________________ State_________________
Social Security Number _________-________-_________ Date of Birth _____-_____-19______
Address: ___________________________________________________________________________
City: ______________________________________ State: _________ Zip Code: ________________

Phone: (________)_________________________ CAUSE #: ________________________________

County of Conviction: ________________________________________________________________

PROBATION OFFICER:____________________________ Phone #: _________________________

DEMOGRAPHIC - Circle one in each category

GENDER ETHNICITY MARITAL STATUS

Male White Black Married Never married
Female Hispanic Asian Separated Divorced
American Indian Other Widowed Single

FAMILY AND DEPENDENTS

How many times have you been married? ___________ How many Children? __________
How many dependents, other than yourself live with you? Adults _______Children_______
Do you feel your drinking/drug use has contributed to family problems at any time in your life?
YES_____ NO_____
If yes, why?__________________________________________________________________________
____________________________________________________________________________________

EDUCATION
How many years of schooling completed? _______ Highest school grade completed: (Circle One)

None GED/HS Diploma Bachelors Masters Doctorate

What type of work are you trained to do?

_______________________________________________________________________________________
_______________________________________________________________________________________

Are you employed in the type of work you’ve been trained to do at this time? YES _____ NO_____

ARREST INFORMATION - Date of current and previous arrest and charges:

 DATE OF ARREST CHARGE

If charged with DWI, what was the BAC? Present Arrest ______________________________________
Others ______________________________________

How many times has your license been; suspended? __________ revoked? ______________

Prior to this arrest, was your license…

_____OK
_____Suspended Please explain________________________________________________
_____Revoked ________________________________________________
_____Business purpose only ________________________________________________

Your age when you….

began drinking ________

were arrested for first offense_________
were arrested for first alcohol-related offense _________

OTHER INFORMATION
Have you ever thought you might have a drinking problem? YES_____ NO_____
Have you ever received help from …. (circle all that apply)

Family doctor Psychiatrist/psychologist church Friend Relative

Alcohol rehab program Alcoholics Anonymous
Agency (Name: ________________________________________________________________________)
Other: explain:_________________________________________________________________________)

Where do you usually drink? (Please check which apply).

_____Party or social drinking _____Home, by yourself
_____Home, with family, and/or friends _____Bar/Restaurant _______ Other_______

The DWI Education Program is a twelve-hour course and the fee is $70.00. The course is taught in three
days, four hours each day. Participants must register, and schedule in advance.
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 other reason without my signed consent.

Participant signature Date

 San Antonio Council on Alcohol and Drug Awareness

Consent for the Release of Information

I,_______________________________________ __________________________
SACADA Case Number

________________________ __________________________
Date of Birth Social Security Number

Authorize the San Antonio Council on Alcohol and Drug Awareness to release the following
information.

xx_____ Screening / Assessment Results xx_____ Recommendations &

Referrals
xx_____ Program Registration & Completion Dates xx_____ Attendance & Participation
xx_____ Screening / Assessment Results
_______ Other Information____________________________________________________________________

to, and receive Information from:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

______________________________________________________________________________________________

For the purpose of:

_____ Helping me get into Treatment _____ Informing the Pre-Trial Services Office
Connecting me with additional services _____ Keeping the Court Informed
Keeping Family Members informed _____ Informing my Probation/ Parole Officer
Informing my employer or EAP Rep. Keeping my Attorney Informed
_____ Keeping my Union Rep. Informed _____ Making final disposition of this case
Informing School / College Officials _____ Other Purposes: ______________________
_________________________________________________________________________________________________
This consent expires (1 year from start)
(Date or Event)

I understand that I may revoke or cancel this written consent, except to the extent that disclosures may have already been
made based upon it. A copy of this consent form is to be considered as valid as the original consent form.

Notice to Receiving Agency or Person: This information has been disclosed to you from records protected by federal
confidentiality rules (42 CFR Part 2). The Federal Rules prohibit any further disclosure of this information unless further
disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42
CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The
Federal Rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug treatment
patient.

Participant’s Signature Date

Counselor / Other Staff Member’s Signature Date

 Zoom Classroom Etiquette for SACADA Education Courses
The following is a list of Zoom classroom etiquette for the participants attending courses with the San Antonio
Council on Alcohol and Drug Awareness (SACADA). By signing this document, you are agreeing to follow
the list of classroom etiquette. Failure to follow guidelines may lead to dismissal from the program without
completion and with no refund.

1. Participants are encouraged to log in 10 minutes early to ensure audio and microphone work properly.
You must have a working camera and microphone for the course.

2. Participants must be login to course from a distraction-free, quiet environment, no later than 15
minutes after start of class. Failure to do so will result in being absent from course with no refund.

3. Cameras must be on at all times unless on break or instructed so by instructor. Students will need to be
on camera so that your instructor and your peers can see you.

4. Microphones should be on mute unless speaking. If you would like to speak or answer a question, use
the “Raise Hand” feature. Then unmute yourself after you are called on by your instructor.

5. If you would like to use the chatbox, remember that it is public, and a record of the chat is kept and
archived.

6. Please take care of your personal needs (appropriate dress, basic hygiene, eating, chewing gum,
talking to others in your home, etc.) prior to entering a Zoom classroom.

7. Please do not use profanity or inappropriate language.

8. Any inappropriate and/or offensive behavior will have the participant removed from the course.

9. Any individual appearing intoxicated or under the influence will be removed from the course.

10. Have your course materials ready, along with pen/pencil and paper.

By signing this document, you agree to follow the Zoom classroom etiquette for SACADA education courses
and are aware of the possible and probably consequences if not followed.

Participant Signature Date

SACADA Instructor/Staff Signature Date

 NDP - ADAPTED

Name_______________ Date ________

Please read each question carefully, and then check the most correct answer in the box
provided. Check only one box for each question.

1. How many times have you been arrested on charges involving alcohol?
(Do not count the present DWI arrest.) __ (Times)

2. Is someone close to you concerned about your drinking?

Yes( ) No( )

3. With whom did you do most of your drinking before this arrest?
Husband/Wife ( ) Relative ( ) Friends ( )
Strangers( ) Alone( )

4. Do you believe your drinking may be causing you problems?

Yes( ) No( )
No, but it used to cause me problems ( ) Not Sure( )

5. Do you want help for a drinking problem?

Yes( ) No( ) Not Sure( )

6. Do you feel you are a normal drinker?

Yes( ) No( )

7. Have you ever awakened the morning after some drinking the night before and
found you could not remember a part of the evening before?
Yes( ) No( )

8. Does your wife, husband, a parent, or other near relative ever worry or complain
about your drinking?
Yes( ) No( )

9. Can you stop drinking without a struggle after one or two drinks?
Yes( ) No( )

10. Do you ever feel bad about your drinking?

Yes( ) No( )

11. Do your friends or relatives think you are a normal drinker?

Yes( ) No ( )

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12. Do you ever try to limit your drinking to certain times of the day or to certain
places?
Yes ( ) No ( )

13. Are you always able to stop drinking when you want to?
Yes ( ) No( )

14. Have you ever attended a meeting of Alcoholics Anonymous?

Yes ( ) No ( )

15. Have you gotten into fights when drinking?

Yes ( ) No ( )

16. Has drinking ever created problems between you and your wife, husband, parent,
or other near relative?
Yes( ) No( )

17. Has your wife, husband, a parent, or other near relative ever gone to anyone for
help about your drinking?
Yes( ) No( )

18. Have you ever lost friends because of drinking?

Yes( ) No( )

19. Have you ever gotten into trouble at work because of drinking?
Yes ( ) No ( )

20. Have you ever lost a job because of drinking?

Yes ( ) No ( )

21. Have you ever neglected your obligations, your family, or your work for 2 or more
days in a row because you were drinking?
Yes ( ) No ( )

22. Do you drink before noon fairly often?

Yes ( ) No ( )

23. Have you ever been told you have liver trouble? Cirrhosis?
Yes( ) No ( )

24. After heavy drinking, have you ever had Delirium Tremens (DT's) or severe
shaking?
Yes ( ) No ( )

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