DWI Alcohol Evaluation Intake Questionnaire
Please complete this intake form to help us assess your alcohol use and related history for your DWI evaluation.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date of DWI Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Incident (City/State)
*
Have you previously been evaluated for alcohol or substance use?
*
Yes
No
How often do you consume alcohol?
*
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
Alcohol Use Self-Assessment
*
Rows
Never
Rarely
Sometimes
Often
Always
I drink more than I intend
1
2
3
4
5
I have tried to cut down unsuccessfully
6
7
8
9
10
Alcohol use has interfered with responsibilities
11
12
13
14
15
I have driven after drinking
16
17
18
19
20
Others have expressed concern about my drinking
21
22
23
24
25
Have you ever been arrested or cited for DWI or DUI before this incident?
*
Yes
No
On average, how many alcoholic drinks do you consume per week?
*
Is there a family history of alcohol or substance use problems?
Yes
No
Not sure
Please describe any current or past treatment for alcohol or substance use (if applicable):
Submit Evaluation
Should be Empty: