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ALCOHOL EVALUATION #1

EVALUATION 1
LAST NAME, FIRST NAME, M.I.
SPN#
MOST RECENT B LOOD ALCOHOL CONCENTRATION, (BAC), IF TAKEN:
NO. OF ALCOHOL/DRUG ARRESTS (INCLUDE THE MOST RECENT)
NUMBER OF ACCIDENTS IN PAST 2 YEARS:
NUMBER OF MISDEMEANOR ARRESTS IN LIFETIME (DO NOT INCLUDE ALCOHOL/DRUG RELATED ARRESTS):
NUMBER OF FELONY ARRESTS IN LIFETIME:
NUMBER OF ALCOHOL/DRUG TREATMENTS;
TIME YOURSELF ON THIS EXAM.
1. HOW OLD ARE YOU?
2. WHAT IS YOUR RACE?
3. WHAT IS YOUR SEX?
4. HOW MANY YEARS OF SCHOOL HAVE YOU COMPLETED? (HIGH SCHOOL DIPLOMA OR GED = 12).
5. WHAT IS YOUR CURRENT MARITAL STATUS?
6. USING THE SCALE, WHERE 1 IS THE VERY WORST AND 9 IS THE VERY BEST, SELECT THE NUMBER THAT BEST REFLECTS YOUR FEELINGS ABOUT THE MARITAL STATUS YOU SELECTED IN THE LAST QUESTION. VERY WORST 1 2 3 4 5 6 7 8 9 VERY BEST.
7. WHAT IS YOUR EMPLOYMENT STATUS?
8. USING THE SCALE WHERE 1 IS THE VERY WORST AND 9 IS THE VERY BEST, SELECT THE NUMBER THAT BEST REFLECTS YOUR FEELINGS ABOUT YOUR EMPLOYMENT STATUS. VERY WORST 1 2 3 4 5 6 7 8 9 VERY BEST.
9. WHAT IS YOUR LEVEL OF INCOME? (IF MARRIED OR LIVING TOGETHER, GIVE TOTAL OF YOUR INCOME AND YOUR SPOUSE).
10. ARE YOU ALWAYS A GOOD LISTENER NO MATTER WHOM YOU ARE TALKING TO?
11. PICK THE NUMBER THAT BEST REPRESENTS HOW YOU FEEL ABOUT YOUR PHYSICAL HEALTH. VERY WORST 1 2 3 4 5 6 7 8 9 VERY BEST.
12. DOES THE SIGN "NO TURN ON RED" MEAN YOU MUST WAIT FOR THE GREEN LIGHT BEFORE TURNING?
13. DO YOU DRINK AS MUCH AS OR LESS THAN THE AVERAGE DRINKER? (AN AVERAGE DRINKER IS WHATEVER YOU THINK IS AVERAGE. IF YOU DRINK AS MUCH OR LESS THAN AVERAGE ANSWER "YES").
14. ARE YOU ALWAYS CAREFUL ABOUT THE WAY IN WHICH YOU DRESS?
15. HAVE YOU EVER TRIED SOCIAL DRUGS? "POT, COCAINE, ETC," OR STREET DRUGS/ (DO NOT INCLUDE ALCOHOL).
16. HAS A DOCTOR PRESCRIBED MEDICATION TO HELP YOU RELAX?
17. DO PEOPLE THINK OF YOU AS A PERSON WHO CAN DRINK A LOT WITHOUT GETTING DRUNK?
18. DO YOU USUALLY HAVE A DRINK OR TWO BEFORE GOING TO SOCIAL GATHERINGS TO HELP YOU RELAX?
19. DO YOU ALWAYS STOP AND HELP WHEN SOMEONE NEEDS A HELPING HAND?
20. DO YOU HAVE AT LEAST ONE DRINK A DAY, FIVE DAYS OUT OF SEVEN?
21. PICK THE NUMBER THAT BEST REPRESENTS HOW YOU FEEL ABOUT YOUR CURRENT SOCIAL LIFE. VERY WORST 1 2 3 4 5 6 7 8 9 VERY BEST.
22. IN THE PAST TWO YEARS, HAVE YOU TRIED SOCIAL DRUGS? "POT, COCAINE, ETC, OR STREET DRUGS? (DO NOT INCLUDE ALCOHOL).
23. DO YOU BELIEVE YOUR USE OF DRUGS KEEPS, OR HAS KEPT YOU FROM BEING AS EFFECTIVE AS YOU WOULD LIKE? (DO NOT INCLUDE ALCOHOL).
24. ARE YOU SOMETIMES IRRITATED BY PEOPLE WHO ASK FAVORS OF YOU?
25. ARE YOUR TABLE MANNERS AT HOME AS GOOD AS WHEN YOU EAT OUT IN A RESTAURANT?
26. HAVE YOU DRUNK THREE BOTTLES OF WINE (NOT WINE COOLERS) OR TWENTY BOTTLES OF BEER, OR A FIFTH OF LIQUOR (WHISKEY, VODKA, ETC.) IN ONE DAY?
27. DO YOU USUALLY HAVE A DRINK OR TWO WHENEVER YOU ARE DEPRESSED?
28. HAVE YOU FEARED THAT YOU WERE GOING CRAZY OR LOSING YOUR MIND?
29. INDICATE THE NUMBER OF TIMES YOU HAVE BEEN ARRESTED FOR A FELONY OFFENSE. (DO NOT INCLUDE DRUNK DRIVING ARRESTS)
30. CAN YOU STOP DRINKING AFTER TWO DRINKS, WHENEVER YOU WANT?
31. WHEN DRIVING A CAR, IF THE TRAFFIC LIGHT OVER YOUR LANE STAYS RED WHEN ON-COMING TRAFFIC STARTS, SHOULD YOU WAIT UNTIL IT TURNS GREEN BEFORE PROCEEDING?
32. PICK THE NUMBER THAT BEST REPRESENTS YOUR ABILITY TO HANDLE STRESS. VERY WORST 1 2 3 4 5 6 7 8 9 VERY BEST.
33. ON A FEW OCCASIONS, HAVE YOU GIVEN UP DOING SOMETHING BECAUSE YOU THOUGHT TOO LITTLE OF YOUR ABILITY?
34. HAS YOUR FAMILY AND/OR FRIENDS EVER COMPLAINED ABOUT YOUR DRINKING?
35. HAVE YOU EVER KNOWINGLY SAID SOMETHING TO HURT SOMEONE'S FEELINGS?
36. HAVE YOU EVER FELT THAT YOU ABUSED THE USE OF PRESCRIPTION, OR SOCIAL/STREET TYPE DRUG?
37. DO YOU SOMETIMES THINK THAT WHEN PEOPLE HAVE TROUBLES, THEY ONLY GOT WHAT THEY DESERVED?
38. HAVE YOU EXPERIENCED AT LEAST ONE BLACKOUT - A TIME OF DRINKING IN WHICH YOU CARRIED ON ACTIVITIES WITHOUT LATER REMEMBERING THEM?
39. DO YOU USUALLY HAVE A DRINK OR TWO TO CALM DOWN WHEN YOU ARE ANGRY?
40. HAVE YOU BEEN IN TREATMENT OR COUNSELING FOR EMOTIONAL PROBLEMS?
41. HAVE YOU EVER "PLAYED LIKE YOU WERE SICK" TO GET OUT OF SOMETHING?
42. PICK THE NUMBER THAT BEST REPRESENTS HOW YOU FEEL ABOUT YOUR LIFE AT THIS TIME. VERY WORST 1 2 3 4 5 6 7 8 9 VERY BEST
43. DO YOU BELIEVE YOUR USE OF ALCOHOL KEEPS OR HAS KEPT YOU FROM BEING AS EFFECTIVE AS YOU WOULD LIKE?
44. DO YOU FEEL GUILTY ABOUT YOUR DRINKING?
45. HAVE THERE BEEN TIMES WHEN YOU WERE QUITE JEALOUS OF THE GOOD FORTUNE OF OTHERS?
46. BEFORE MAKING A LEFT HAND TURN AT AN INTERSECTION, SHOULD YOU YIELD TO ONCOMING TRAFFIC?
47. IN ORDER TO GET THE SAME EFFECTS, HAVE YOU FOUND YOU NEEDED TO INCREASE THE AMOUNT OF SOCIAL/STREET DRUGS YOU WERE TRYING? (DO NOT INCLUDE ALCOHOL).
48. HAVE YOU EVER BEEN IRRITATED WHEN PEOPLE EXPRESSED IDEAS VERY DIFFERENT FROM YOUR OWN?
49. AT TIMES, HAVE YOU REALLY INSISTED ON HAVING THINGS YOUR OWN WAY?
50. INDICATE THE NUMBER OF TIMES YOU HAVE BEEN ARRESTED FOR AN ALCOHOL/DRUG RELATED OFFENSE?
51. INDICATE THE NUMBER OF TIMES YOU HAVE BEEN IN A TREATMENT PROGRAM FOR ALCOHOL OR DRUG PROBLEMS. (DO NOT INCLUDE COURT-ORDERED SUBSTANCE ABUSE EDUCATION).
YOU HAVE COMPLETED PAGE 1. NOW CLICK ON PAGE 2 AND COMPLETE THAT FORM. THANK YOU
YOUR FULL NAME
YOUR SPN#
YOUR CAUSE NUMBER:
WHAT IS YOUR CHARGE? (IF THIS IS A DWI, PLEASE STATE IF THIS IS YOUR 1ST, 2ND, 3RD, ETC.)
YOUR CELL PHONE NUMBER
YOUR MAILING ADDRESS INCLUDING THE ZIP CODE
YOUR PROBATION OFFICER'S NAME
PROBATION OFFICER'S FAX NUMBER
DATE COMPLETED EVALUATION.
TIME THE EVALUATION --PAGE 1 WAS COMPLETED.
PLEASE CONTINUE TO PAGE TWO OF THE EVALUATION.
THE TIME SPENT ON PAGE 1 OF EVALUATION (HOW MANY MINUTES?)
REMINDER: PAY FOR YOUR EVALUATION NOW. GO TO HOME PAGE, CLICK ON "PAY HERE" AND FOLLOW PROMPTS AND PAY WITH ANY DEBIT OR CREDIT CARD. IF YOU DON'T HAVE A CREDIT OR DEBIT CARD, PLEASE CALL RICHARD TO LEARN HOW TO SEND A WESTERN UNION MONEYGRAM--832-257-59956.
NOTICE: IF YOU DON'T PAY,YOUR EVALUATION WILL NOT BE PROCESSED.
NOTICE: THERE ARE 98 QUESTIONS ON THIS EVALUATION. GO TO HOME PAGE AND CLICK ON "EVALUATION 2" FOR QUESTIONS 52 THRU 98. THANK YOU.
CURRENT CHARGE:
DATE OF BIRTH:
CURRENT E-MAIL ADDRESS:
PLEASE GIVE US ANY INFORMATION THAT WILL HELP US COMPLETE YOUR CERTIFICATE.

 NOTICE:  OUR COUNSELORS WOULD PREFER THAT YOU HAVE A PHONE INTERVIEW BEFORE STARTING THE ALCOHOL & DRUG EVALUATION.  WE FIND OUR CLIENTS HAVE A BETTER UNDERSTANDING AND LESS TEST ANXIETY.