Participant Forms Download PDF Student Manual Full Name(Required) First Last DemographicSelect one in each categorySexMaleFemaleOtherI rather not sayEthnicityWhiteBlackHispanicAsianAmerican IndianMartial StatusMarriedNever MarriedSeparatedDivorcedWidowedSingleOtherArrest InformationDates of current and previous arrest and charges:Date of Arrest #1 MM slash DD slash YYYY Charge Reason #1 Number of arrests Add 1 more incident Add 2 more incidents Date of Arrest #2 MM slash DD slash YYYY Charge Reason #2 Date of Arrest #3 MM slash DD slash YYYY Charge Reason #3 Charge # Probation Officer If charged with DWI, what was the BAC? Present Arrest Other Arrests (if applicable)How many times has your license ever been:SuspendedRevokedRestrictedPrior to this arrest, was your license: OK Suspended Revoked Restricted Select oneReason Your age when you:began drug activitiesbegan drinking alcoholwere arrested for first offensewere arrested for first drug-related offenseWhat are your drugs of choice? Other InformationHave you ever thought you might have a drug problem? Yes No Select oneHave you ever thought you might have a drinking problem? Yes No Select oneHave you ever received help from: Family Doctor Church Drug/Alcohol Rehab Program Narcotics Anonymous Psychiatrist/Psychologist Relative/Friend Treatment Program Agency Other Select all that applyWhere do you usually use drugs? Party or social event Home, with family, friends Work or School Home, by self Night club On the street Other Select all that applyName of Agency Explain Consent acknowledgement(Required) I understand that information about me and my progress in this Drug Education Course 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 reason without my signed consent.eSignatureDate submitted: April 3, 2025
