Enrollment Information and Informed Consent

  • Enrollment Information and Informed Consent

    Please complete your enrollment details and review the informed consent section before submitting. If this is not completed within 2 business days of making your enrollment appointment, you appointment will be cancelled and given to another participant. Please complete immediately.

  • Enrollment Information

  • Today's Date*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Client's Date of Birth*
     - -
  • Date of most recent DUI arrest*
     - -
  • Have you attended Cascade Circle DUI program before?*
  • If you have a pending case when is your next court date? (00-00-0000 if none)*
     - -

  • Informed Consent

  • DUI program services in California must be completed through the Department of Health Care
    Services (DHCS) licensed DUI program. California’s Health and Safety Code (HSC), Division
    10.5, Part 2, Chapter 9, Section 11836 establishes the DHCS as having the sole authority to
    license DUI Programs to provide alcohol or drug recovery services to a person whose license to
    drive has been administratively suspended or revoked for, or who is convicted of, a violation of
    Section 23152 or 23153 of the Vehicle Code (VC), and admitted to a program pursuant to
    Section 13352, 23538, 23542, 23548, 23552, 23556, 23562, or 23568 of the Vehicle Code.

    Pursuant to Title 9, California Code of Regulations (CCR), Chapter 3, Section 9848, a DUI program
    may enroll any person who presents documentation from the court or the DMV verifying his/her
    arrest or conviction for a DUI violation specified in HSC Section 11836 as referenced above. To
    ensure timely program enrollment, DHCS will allow several types of documents generated by the
    DMV or court. (See DHCS acceptable Enrollment Document Matrix)

    Although DHCS licenses DUI program services, program requirements are ultimately dependent
    on offenses specified in California Vehicle Code, and interpreted by the California Department of
    Motor Vehicles (DMV)-Mandatory Action Unit (MAU), in conjunction with the court of conviction.

    When enrolling in a DUI program following arrest for a DUI offense prior to a conviction, the DUI
    program will enroll you in the most appropriate program type based on the information contained in
    the enrollment documents you present along with any additional information you are able to
    provide at that time. DHCS encourages you to contact the DMV-MAU at (916) 657-6525 if you
    have questions/concerns specific to the type of DUI program you will ultimately be required to
    complete.

    Please note, following your initial DUI program enrollment there may be instances in which DMV’s
    MAU review of your DUI offense/driving history and/or court proceeding may necessitate a
    modification of the program type you are/were initially enrolled in. In all instances, you are
    financially responsible for all DUI program services received and/or incurred during your
    enrollment in a DUI program. (Additional program service fees are identified in the participant
    contract you will review and sign at the time of DUI program enrollment)

    The following consent/agreement and required enrollment documents must be completed and
    placed in your participant file as required by CCR, Title 9 requirements. As with all documents
    produced during your DUI program enrollment and participation, you are encouraged to retain
    copies for your records.

  • Please sign below to acknowledge this disclaimer.

  • Work Schedule and Availability

  • This information is extremely important in helping us schedule your program sessions and ensure timely completion of your program. Please keep in mind that if you do not make time available to attend your required sessions, your completion date may be significantly delayed. The more availability you provide, the easier it is for us to schedule you into services.

    We offer a wide variety of class days and times in an effort to accommodate participants’ schedules. Most classes are available during evening hours throughout the week. We also offer some daytime classes, as well as weekend classes on Saturdays and Sundays, to help fit your scheduling needs whenever possible.

    Please also note that changes made to your schedule after it has been created will result in a $25.00 rescheduling fee.

    Please clearly list the days and times you are unavailable.

     

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  • So what are your top three days you would like to attend?*
  • Are there days that you are absolutely unavailable?*

  • Disclaimers

    • Be sure you fill this out accurately.
    • There is a $25.00 rescheduling fee to change your schedule once we have begun working on the schedule using this worksheet. We begin working on this when you arrive for your appointment so if there are any changes please let us know at your appointment right away.
    • 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.
    • If you want us to notify court of your enrollment you will need to email documents to cascadecircle@cascadecircle.net.
    • Please see that our website has a lot of information and can answer a lot of your questions.
    • After we received this document we will send you confirmation of your appointment with further instructions.
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