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DUI and/or Substance Use Services New Client Questionnaire
Fill out this questionnaire to get started with Counseling Speaks.
* Indicates required question
Email
*
Your email
Full Name
*
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Age
*
Your answer
Phone Number
*
Your answer
Preferred Method of Contact
*
Call (no voice messages)
Call (okay to leave voice messages)
Email
Required
What type of DUI/Substance Use service are you seeking?
*
DUI Evaluation
Non-Dui Alcohol and Drug Evaluation
DUI Counseling/Classes (minimal, moderate, significant, high-risk classifications)
Evaluation & Recommended Counseling/Classes
Aftercare
Early Intervention
License Reinstatement Services
Outpatient Substance Use Counseling
Not sure; need help navigating what services I need
Required
Is this service court-ordered?
*
Yes
No
Will you require any alcohol/drug testing services?
*
Yes
No
Maybe; not sure at this time
Is there anything else you feel like we should know in order to best meet your needs?
Your answer
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