EVALUATION FACE SHEET
Center for Addiction and Family Counseling
Centro de Adicción y Consejería Familiar
Evaluación Face Sheet
Assessment Date: ___________________
Patient Last Name___________________________ First Name ___________________________Age_______ DOB ____________
Address _____________________________________Apt. No_________ Marital Status________ Sex______ Race_____
City______________________________ State____________ Zip____________ SS #_____________________________________
Telephone (home) _________________Cell ________________________Occupation_______________ Nationality______________
Reason for Visit
In case of Emergency
Attorney at Law: _____________________________________________ add text, images, and other content
CLINICAL EVALUATION CONTRACT
JAVIER ELIZALDE, NCAC II, CCS, CCDPD
DHR # 1669
Clinical Evaluation Contract
Anyone who gets a DUI in Georgia is required to attend DUI School, have a clinical evaluation from a State approved Clinical Evaluator, and complete any treatment recommendations with a State approved Treatment Provider. These requirements, effective 7-1-1997 and 7-1-2008, are State law. The State approved evaluators and treatment providers can be found on the web at www.mop.uga.edu. Other conditions may be required for license reinstatement fees. Call the Department of Drivers Services at 678-413-8400 for information on your case.
- The client must complete DUI School before having a clinical evaluation.
- The client will select a clinical evaluator from the State Registry and have the DUI School forward the NEEDS assessment to that evaluator.
- The client may select any evaluator they wish from the Registry.
- The client is entitled to a second opinion.
- The client will select a treatment provider from the State Registry. If this is not done within 60 days of the evaluation, the evaluator may conduct another evaluation.
- The client will pay the clinical evaluation fee of $95 or _____ in full at the time of service.
The Clinical Evaluator (CE) attests that they are currently on the State Registry of approved clinical evaluators.
- The CE will determine the level of treatment recommended not the place or length of treatment.
- The CE will show the client the list of State approved treatment providers on the Registry.
- The CE will forward the necessary forms and information to the selected treatment provider after the client signs the necessary release of information form.
I have read and understood the terms of this agreement. I have received a copy of the contract.
Client Signature Date
Clinical Evaluator Signature CE# 1669 Date
DUI INTERVENTION PROGRAM
IMPORTANT INFORMATION - PLEASE READ CAREFULLY
The purpose of the Risk Reduction Program is to help people who have experienced a problem because of their use of alcohol or other drugs. Your DUI, drug possession, or other charge may not be the first time you have had a problem because of your use of alcohol or drugs. The program will teach you how to reduce your chances of having future alcohol or drug related problems.
COMPLETION OF THE DUI, ALCOHOL OR DRUG RISK REDUCTION PROGRAM!
Some offenses that require completion of the DUI, Alcohol or Drug Risk Reduction Program (DUI SCHOOL) are DUI, Drug Possession, and Underage Alcohol Possession While Operating a Vehicle. Judges will sometimes order people to attend the Risk Reduction Program for other offenses. At the Risk Reduction Program you will take an assessment, and attend a
20-hour Intervention course. The results of your assessment are confidential, and will not appear on your driving record. You will learn about your assessment results during class. If you have questions, please talk to your Instructor after you begin class.
It is against the law for anyone to tell you that you have to attend a particular DUI Risk Reduction Program (DUI school).
A Judge or Probation Officer may require you to bring proof that you completed the DUI School, but they cannot tell you which school you have to attend.
IF YOU HAVE RECEIVED 2 OR MORE DUI’S IN THE PAST 10 YEARS
If you have a DUI arrest after 7-1-08, the law requires persons who have received 2 or more DUI in a ten-year period to get a substance abuse clinical evaluation and, if necessary, complete a treatment program in order to regain their drivers license. For arrests prior to 6-30 -08, the period is five years.
IF YOU ARE FIRST TIME DUI OFFENDER
For DUI arrests after 7-1-08, all first DUI offenders are required to have a clinical evaluation and complete treatment if recommended as a standard condition of probation unless specifically waived by the judge for first offenders.
FOR ALL DUI’S
After you complete the Risk Reduction Program, you must get a clinical evaluation. This clinical evaluation is different from the assessment questionnaire you completed at the Risk Reduction Program. The Evaluator is a substance abuse professional who will interview you in person. He/she will have the results of your assessment survey from the DUI School to review before meeting
with you. The Risk Reduction Program will provide you with the registry from the Georgia Department of Behavioral Health & Developmental Disabilities (DBHDD) listing all approved Evaluators in your area. You may choose any Evaluator on the registry. After you choose an Evaluator, you will need to sign a Release of Information form and pay a $10.00 transfer fee, so that the Risk Reduction Program can send a copy of your assessment to the Evaluator. The costs for each Evaluator are listed on the registry, and start at $95.00. If the Evaluator offers reduced prices based on your income, that will be listed on the registry as sliding scale available. You will have to call or go to the Evaluator to see if you qualify for a reduced price. Some Risk Reduction Programs may have a Clinical Evaluator available, but you are not required to get your clinical evaluation at their facility.
After completing the clinical evaluation, the Evaluator may recommend that you attend a Treatment Program. The Clinical Evaluator will make a recommendation for the level of service you need and give you a DBHDD -approved registry of treatment providers in your area. The Evaluator and the Risk Reduction Program cannot refer you to a particular Treatment Provider; that is your responsibility. In addition, you cannot receive treatment services from the person who does your clinical evaluation. If you have someone in mind for treatment, do not select that person for your clinical evaluation.
NOTE: To be eligible for driver’s license reinstatement, you have to go to a Clinical Evaluator and Treatment Provider that are on the DBHDD-approved registry.
I have read the above information, or the program has read it to me. I have received a copy of this form.
Student Signature Date
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