DWI EDUCATION 12 HRS

WEEKEND CLASS

REGISTRATION FORM

-COMPLETE REGISTRATION FORM

-A SECOND EMAIL AFTER YOUR RECEIPT WILL BE EMAILED TO YOU WITH THE PRE-TEST AND CLASS MEETING LINK

-COMPLETE THE PRE TEST AT YOUR EASIEST CONVENIENCE.

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

DRIVERS LICENSE/ SOCIAL SECURITY

Name of Probation Officer/Parole Officer/Lawyer & County

Probation/Parole/ Office/ Lawyer Email

COUNTY OF CONVICTION (TYPE IN USING OTHER IF NOT LISTED)*

Highest Level of Education

How many times has your license now or ever been?

Please list the dates and charges for any previous and current arrests:

If charged with DWI, what was the BAC?

What is your drug of choice?

Have you ever thought you might have a drug problem?

Have you ever thought you might have a drinking problem?

Reason you were stopped

Drinking alcohol after work

Engaged in a recreational activity, while using alcohol ( or drugs)

Coping with problems ( relationship, work, family, etc.)

Other

During the weekdays I tend to drink on what days

During the week-ends I tend to drink ( drug use) on

Summarize any other comments about your drug/alcohol usage and the events leading up to your arrest below:

COST OF GETTING A DWI

Fines and Court Costs/Loss of Salary/ Bond

Temporary transportation (bus, cab, rental/lease car, etc.).

DWI Education Course Fee:

Driver License Surcharges

Alcohol/ Drug Programs/Counseling/ Treatment

Increased Cost of Insurance

NDP-adapted:

Please read the question carefully and then check the most correct answer in the box provided. Check only one.

1. How many times have you been arrested on charges involving alcohol?

2 Is someone close to you concerned about your drinking?

Yes

4. Do you believe your drinking may be causing you problems?

Yes

5. Do you want help for a drinking problem?

Yes

Not sure

6. Do you feel you are a normal drinker?

Yes

7. Have you ever woken up the morning after drinking and found that you couldn't remember part of the night before?

Yes

8. Does your wife, husband, a parent or other close relative ever worry or complain about your drinking?

Yes

9. Can you stop drinking without a struggle after one or two drinks?

Yes

10. Do you ever feel bad about your drinking?

Yes

11. Do your friends or relatives think you are a normal drinker?

Yes

12. Do you ever try to limit your drinking to certain times of the day or to certain places?

Yes

13. Are you always able to stop drinking when you want?

Yes

14. Have you ever attended an Alcoholic Anonymous meeting?

Yes

15. Have you gotten into fights when drinking?

Yes

16. Have you gotten into fights when drinking?

Yes

17. Has your wife, husband, a parent or other near relative gone to anyone for help about your drinking?

Yes

18. Have you ever lost friends because of drinking?

Yes

19. Have you ever gotten into trouble at work because of drinking?

Yes

20. Have you ever lost a job because of your drinking?

Yes

21. Have you ever neglected your obligations , family, or your work for 2 or more days in a row because you were drinking?

Yes

22. Do you drink before noon fairly often?

Yes

23. Have you ever been told that you have liver troubles? Cirrhos.

Yes

24. After heavy drinking, have you ever had Delirium Tremens (DT's) or severe shaking?

Yes

25. After heavy drinking, have you ever heard voices or seen things that weren't really there?

Yes

26. Have you ever gone to anyone for help about your drinking?

Yes

27. Have you ever been in hospital because of drinking?

Yes

28. Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital?

Yes

29. Have you ever been in to "dried out" (detoxified) because of drinking?

Yes

30. Have you ever been in jail, even for a few hours , because of drunk behavior? ( Count the present arrest)

Yes

Atlas Counseling and Education LLC

DWIE REGISTRATION FORM

DWI EDUCATION PROGRAM.

All persons assigned to attend the Offender Education Program must successfully complete the following: Course regulations:

-For all virtual students, I understand that if my internet connection is not reestablished within 5 minutes, I will be dropped from the class and no refunds will be given.

-Threats and any actions that may be perceived as harmful may result in immediate dismissal from the class, and authorities will be notified

No foul language, please.

-I understand that these rules are met to ensure the safety and best interest of all in the classand they are not to be debated.-

I understand that I have been provided the information at the time of registration and I am solely responsible to read and follow these rules.

-I understand that I am responsible for my homework assignments and must be completed in atimely fashion.

-I understand that if I fail to complete all the class requirements and do not attend any make-up classes.

-I understand that if a situation arises and the class is canceled, then the class will be rescheduled at the earliest date possible.

-I understand that I need to ensure that payment has been made in order to be allowed in class.

-I understand that all assignments and pre- and post-tests must be completed and submitted within 1 hr of completing the class. Failing to do so may cause a delay or result in being dropped entirely.

-I understand that eating is highly discouraged when in class.

- I understand that privacy matters are taken very seriously and I will make an effort not to bother others without a personal headset.-I understand that it is highly recommended that I attend class in a secure and private location where I can express my opinions and without the concern of others listening to responses.

-I understand that I am obligated to participate in all class discussions and will answer questions when asked appropriately.

-I understand that I am not to wander around my location for any reason.

-I understand that for no reason am I or anyone else allowed to record the class sessions.

-I understand that I must have my camera on and be in view of the cameras at all times.

-I understand that I may not engage in watching TV, social media, having side conversations, or any other activity that may be disruptive to the class.

- I understand that I cannot attend class if I am driving, working, or engaged in personal errands, e.g., shopping, working, driving, cooking, doing yard work, bathing, or any other activity that maybe distracting to the class)-I understand that family emergencies, flat tires, babysitting, going to work and other situationssuch as this will result in a non-excused absence.

-No absences are all in all courses

-All classes must be completed in their proper sequence and no makeup class will be allowed for DWIE

-Students are not to be driving, sitting in a moving car, or sitting or attending class in a public area.

-No other individuals are allowed on camera or in the area where you are attending the class.

-I understand that it is my responsibility to have a reliable internet connection and Atlas.- Counseling and Education has no responsibility to ensure that your internet connection is reliable.

-No sleeping is allowed for any reason.

- Please wear appropriate clothing, especially clothing that does not promote drug and alcohol use, and over-revealing clothing

- It is the client’s responsibility to know what class is needed. No refunds will be given for any reason.

- I understand that I am not to flirt or ask other participants on dates of given compliments of any kind that may be found to be unwelcome or offensive.

-I understand if I fail to comply with any or all of these rules, I may be dropped from the class andyour probation officer will be notified within 24 hrs. Failing to appear in this class will lead to forfeiting your payment, and no credit or refund will be given for any reason.

Release of Information Notice

By enrolling in services with Atlas Counseling & Education LLC, the client acknowledges and agrees that information related to their participation may be released to authorized entities involved in their case. This may include, but is not limited to, probation officers, courts, attorneys, and referring agencies for the purpose of verifying enrollment, attendance, progress, compliance, and completion of required services.

This release is limited to the minimum necessary information required to fulfill legal, court, or referral obligations and is conducted in accordance with applicable confidentiality laws and regulations.

Financial Responsibility & Payment Authorization

I understand that I am voluntarily enrolling in services provided by Atlas Counseling & Education LLC. By submitting payment, I confirm that I am the authorized cardholder or have permission from the cardholder to complete this transaction.

I acknowledge that I am responsible for selecting the correct program or service required by my court, community supervision officer, attorney, or other referring entity. Atlas Counseling & Education LLC does not determine eligibility or required level of care, and no guarantees are made regarding acceptance of services by any third party.

I understand that all sales are final. No refunds will be issued for any reason, including but not limited to enrolling in the incorrect program, failure to attend sessions, removal from the program due to policy violations, or failure to complete program requirements.

I agree not to initiate a chargeback, dispute, or reversal of payment through my bank or credit card provider without first contacting Atlas Counseling & Education LLC to attempt to resolve the matter.

In the event that a chargeback, dispute, or payment reversal is initiated, I authorize Atlas Counseling & Education LLC to provide the minimum necessary information required to respond to and resolve the dispute. This may include proof of payment, signed agreements, and relevant communication records.

I understand that any disclosure will be limited in accordance with applicable privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA), and any other applicable federal or state confidentiality regulations.

I understand that submitting a chargeback does not cancel my financial obligation, and I remain responsible for any outstanding balance owed for services rendered or made available.

I understand that I am selecting the correct program required by my court or supervising authority. I understand that all payments are final and non-refundable, and that failure to attend or complete the program does not entitle me to a refund.

I have read and agree to the Financial Responsibility, No-Refund Policy, and Chargeback Terms.

Hand Signature Only

I am responsible for all program fees, due as stated at registration. Full payment is required to receive credit or a certificate. In case of a dispute or chargeback, I authorize Atlas Counseling & Education LLC to provide limited documentation to verify.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Choose the Class Below to continue to payment.

DWIE WEEKEND CLASS$90