Enrollment Application & Availability Schedule

DUI PROGRAM ENROLLMENT INFORMATION & INFORMED CONSENT & AGREEMENT

Todays Date*

Date

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What town did you receive yur DUI Violation in?*

What is the date of your most recent DUI arrest*

Violation Date

How many DUIs do you have in 10 years*

Have you ever attended our program before?*

Attended with Cascade Circle before yes or no

Are you reinstating into our program after termination*

Phone #*

Email*

example@example.com

Sex*

Driver's License Number*

Client Date of Birth*

Age:*

What length of program do you need to take*

Ordered by DMV and/or Court

Are you COURT ordered to take the program*

Yes or No

Would you like to attend Live Virtual Services (ZOOM) or attend in person at the Redding Office?*

Enrollment Appointments are in person unless you live OVER 1 hour away. How far away do you live?*

Note from client

I certify that all information provided is accurate and that I have read and understand all pre-enrollment instructions. I acknowledge that submitting more than one pre-enrollment form may delay processing and result in my request being placed at the bottom of the queue. I will not submit multiple forms.

Signature

WORK AND AVAILABILITY SCHEDULE

TIMES FOR YOUR ENROLLMENT APPOINTMENT

We do enrollments on Tuesdays, Wednesdays & Thursdays only during the day as it has to be when the office staff is present. All other program sessions can be scheduled for daytime, evenings and even weekends. Please mark YES or NO on the options we have and we will place you in the earliest possible spot we have available. We will email you with the date, time and important information you will need for the appointment according to what you place here. The appointment takes about one hour and is held in the Redding office unless you live more than one hour away via Google Maps only then can your enrollment be via Zoom.

If you are Reinstating into our program we do ALL REINSTATMENT appointments via Zoom on Tuesdays at 2:30

Tuesdays 11:00 am*

Tuesdays 12:30pm

Wednesdays 10:00am*

Wednesdays 11:30am*

Wednesdays 1:30 pm*

Thursday's 1:30*

Thursday's 3:00pm*

I need to reinstate into the program and will need a Tuesday Zoom appointment for 2:30 pm*

TIMES FOR GROUP, EDUCATION & FACE-TO-FACE INTERVIEWS

This information is extremely important for scheduling your program session in order to get you completed timely. Please keep in mind that if you do not make time to attend this program then it will greatly prolong your program completion. The more you are available for us to schedule you the easier it is to get you into services. Please be clear the days and time YOU ARE NOT AVAILABLE.

Are you attending your program sessions on Zoom or In Person?*

Zoom or in the office?

Are you currently working*

Yes or No

What type of work do you do*

How long does it take you to get home from work*

How long does it take you to get to our office from your work*

Please list the hours your work each day (NOT Available for sessions due to work) Example 8am-5pm

Monday*

Tues*

Wed*

Thurs*

Friday*

Sat*

Sun*

OTHER COMMITMENTS: (Keep in mind the more you are unavailable for sessions the longer the program may take to finish. Example 10am-2pm

Monday*

Tues*

Wed*

Thurs*

Friday*

Sat*

Sun*

Is there a day that would be absolute best for you to attend sessions if possible*

If you do not write out the time you are NOT available, we will assume you can attend during that time. Be sure you fill this out accurately. There is a $25.00 Rescheduling fee to change your schedule. *** It is of utmost importance that you keep your contact information current with us at all times. It is also very important that you watch your email carefully for updates regarding your schedule and program. Is there anything you would like to share regarding your schedule?

Note regarding schedule...

Client Signature