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New Customer Data Entry Form
This form collects the information to begin your case.
* Indicates required question
Email
*
Record my email address with my response
Full Complete Legal Name
(First name, Middle name, & Last name)
*
Your answer
Area Code Phone Number (No Dashes)
Please omit dashes; Numbers only.
*
Your answer
Mailing Address (Physical mailing address)
*
Your answer
City, State, & Zip Code
*
Your answer
Date of Birth (MM/DD/YYYY)
*
Your answer
North Carolina Drivers License Number
(leave blank if you do not have a NC DL #)
Your answer
Social Security Number
(we need your SSN to pull your driving history)
No dashes; numbers only please
*
Your answer
Male or Female (Gender)
*
Male
Female
Required
Race (required by the DMV, you can choose more than one)
*
American Indian/ Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Hispanic
Required
Ethnicity (also required by DMV)
*
Hispanic Puerto Rican
Hispanic Mexican American
Hispanic Cuban
Hispanic Other
Unreported
Not Hispanic or Latino
Required
Marital Status
*
Never Married
Now Married
Divorced
Separated
Widowed
Required
Education (highest level)
*
Less than 6th grade
Less than 9th grade
Less than 12th grade
Completed HS / GED
Some College
Bachelors Degree
Graduate Degree or higher
Required
Employment
*
Full time
Part time
Unemployed
Not in the labor force
Required
Health Insurance Provider Name
(Leave blank if you do not have health insurance)
Your answer
State on Drivers License
(blank if licensed to drive in North Carolina)
Your answer
Out of State Drivers License #:
Your answer
Emergency Contact Person Name
Your answer
Emergency Contact Phone Number
(no dashes; numbers only)
Your answer
Allergies
Your answer
Prescribed Medications
Your answer
Have you been assessed for current charge?
*
Choose
Yes
No
Agency that did your most recent assessment?
Your answer
Who referred you to Beyond Addiction?
Your answer
Attorney Name (Agency)
Your answer
Attorney Phone Number
(please no dashes; numbers only)
Your answer
Attorney Fax Number
(please no dashes; numbers only)
Your answer
Attorney Email Address
Your answer
Docket # (if more than one docket #, please separate docket numbers with a comma)
Your answer
County of Arrest of Offense County
*
Your answer
Blood Alcohol Concentration (BAC)
*
Refusal
Substance Other Than Alcohol
Unknown Underage Charge
Blood Test
Unknown Blood Alcohol
Other:
Required
Number of Prior DWI Offenses
*
No Priors
One Prior
Two Priors
Three Priors
More than three priors
Required
Date of Offense (Arrest Date)
*
MM
/
DD
/
YYYY
Offense
*
Choose
DWI
DWLR
Open Container
Other
Anger Management Counseling
Trial Date (next court date)
MM
/
DD
/
YYYY
Conviction Date (if convicted)
MM
/
DD
/
YYYY
Notes: List any special circumstances you would like us to know up front.
Your answer
Do you have a probation Officer?
*
Your answer
Current Age
*
Your answer
How many arrests in your life time?
(Any and all arrests; Approximate number)
*
Your answer
Your Household Size (You, Spouse, and dependents)
*
Your answer
Have you ever had any substance use treatement?
*
Choose
None
Inpatient
Outpatient
Multiple
Education only
Submit
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