IDRC Screening Form & Autobiographical Statement "*" indicates required fields Name* First Last Email* Phone Number you can be reached for screening during class*Date of Birth* MM slash DD slash YYYY Have you ever attended self-help meetings (AA, NA, CA, etc.)?* Yes No Do you currently attend self-help meetings (AA, NA, CA, etc.)?* Yes No Have you ever participated in treatment for substance use?* Yes No Are you currently enrolled in treatment for substance use?* Yes No DUI Incident InformationAt the time of your DUI/RF, what substance(s) were you under the influence of? List all that apply.*How much did you use?Do you currently have a pending DUI conviction?* Yes No Instructions For Autobiographical StatementThis statement should be a short (500 words or less) account of what happened and how you felt on the day of your arrest. Emphasize the events that led up to the arrest or incident and what it was that brought you to the attention of the police, NOT what the police did once they arrested you. State how you think you could have avoided getting into this situation. What follows is a list you will find helpful in organizing your story. It is, however, only a guideline. If there are other items you which to include, feel free to do so. Indicate:* What day of the week and time of the day did the incident happen Was it a routine day What were you drinking The amount you had to drink was your usual amount Were you using any other drugs, other than alcohol, at the time of your DUI Were you feeling cheerful, depressed, happy, angry or generally nervous There was a family problem, fight or a problem with a loved one Something happened to a family member or loved one The drinking occasion was a special event (such as a wedding, company picnic, etc.) Were you drinking or using drugs for relief from pain. You think the amount you drank was related to your mood Please write your statement below. Please use prompts 1-11 above as a basis for your response. Use In The Last Six Month'sFor the following questions, please be sure to answer regarding your use in the last 6 months:In the last six months, have you used alcohol or other drugs (such as wine, beer, hard liquor, pot, coke, heroin, other opiates, uppers, downers, hallucinogens, inhalants)* Yes No In the last six months, have you felt that you use too much alcohol or other drugs?* Yes No In the last six months, have you tried to cut down or quit drinking or using drugs?* Yes No In the last six months, have you gone to anyone for help because of your drinking or drug use? (such as Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, counselors, or a treatment program)* Yes No In the last six months, have you had any of the following? Put a check mark next to any problems you have experienced:* Blackouts or other periods of memory loss? Injury to your head after drinking or using drugs? Convulsions or delirium tremens (DTs)? Hepatitis or other liver problems? Felt sick, shaky, or depressed when you stopped drinking or using drugs? Felt "coke bugs" or a crawling feeling under the skin after you stopped using drugs? Injury after drinking or using? Used needles to shoot drugs? No, I have not experienced any of the above problems In the last six months, has drinking or other drug use caused problems between you and your family or friends?* Yes No In the last six months, has your drinking or other drug use caused problems at school or at work?* Yes No In the last six months, have you been arrested or had other legal problems? (such as bouncing bad checks, driving while intoxicated, theft, domestic violence, or drug possession)* Yes No In the last six months, have you lost your temper or got into arguments or fights while drinking or using drugs?* Yes No In the last six months, do you need to drink or use drugs more and more to get the effect you want?* Yes No In the last six months, have you spent a lot of time thinking about or trying to get alcohol or other drugs?* Yes No Lifetime UseFor the following questions, please be sure to respond regarding your lifetime use:In your lifetime, have you ever had a drinking or other drug problem?* Yes No In your lifetime, have any of your family members ever had a drinking or drug problem?* Yes No Do you feel that you have a drinking or drug problem now?* Yes No Signature*By signing below, I certify all information is true and correct to the best of my knowledge:CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
