DUI Screening & Treatment

Informed Consent for DUI Screening Education and Treatment

I_____________________________________ DOB:_____________ Case No.______________ request to be accepted for DUI Screening.

  1. Name of Referring Court: _________________________________________________________________________________________________
  1. Address of the Referring Court: ______________________________________________________________________

I have been informed of the following policies about the DUI Screening, Education and Treatment:

_____DUI Screening (30 – 45 min.) _____ DUI Education – 16 hours

_____ DUI Treatment is based on the DUI Screening/provider and/or referring court and includes at least 20 hours of group counseling and is scheduled to be completed within 16 weeks after enrollment.

DUI Screening Process and Type of screening and its Time and Cost /method of payments:

SASSI-4 is a screening tool that reflects the alcohol and drug frequency responses bases on the past twelve months. The screening gathers information regarding Demographics, previous DUI/DWI Arrests, prior Treatment Attempts and Current use of any drugs and/or Prescription drugs

Session/Time: The SASSI-4 screening is takes about 30-45 minutes, Group Sessions are 90 minutes to 180 minutes, Individual sessions 50 minutes


Initial Assessment $140.00

The cost of the DUI/SASSI-4 Screening is $90.00

DUI Education and Treatment per group session is $35.00

DUI Education and Treatment per individual session is $50.00

(Method of payment is Cash or Credit Card)

The court will be notified within 7 days if you fail to comply with guidelines and upon your completion. Consequences of non-compliance may result in jail time or fees)

Client Signature: ________________________________________________________ Date: _______________

Staff Signature: _________________________________________________________ Date: _______________

Please download, complete and bring it to your first appointment:

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