Enrollment Form

RCS Enrollment Agreement

Today's Date(Required)

Personal Information

Name(Required)

First Last

Mailing Address(Required)

Street Address City State ZIP Code

Email(Required)

Cell Phone(Required)

Date Of Birth(Required)

Age(Required)

Marital Status(Required)

Married

Single

Divorced

Widowed

Sex(Required)

Male

Female

Your Health Status(Required)

Excellent

Good

Fair

Poor

Violation Date(Required)

Drivers License #(Required)

Driver's License Issuing State(Required)

Auto Make(Required)

Auto Model(Required)

Auto Year(Required)

Auto Color(Required)

Auto License Plate #(Required)

Number of Children(Required)

Please enter a number from 0 to 10.

Do they live with you?(Required)

Yes

In case of emergency, please notify:

Emergency Name(Required)

First Last

Emergency Phone(Required)

Relationship to you(Required)

Emergency Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Self-Assessment

Which of the following do you consider yourself as?(Required)

Was your drinking/using at time of arrest related to:(Required)

Have you ever thought about cutting down on drinking/drug use?(Required)

Yes

Are you concerned about your drinking/drug use?(Required)

Yes

Have you ever thought about cutting down on drinking/drug use?(Required)

Yes

Are you concerned about your drinking/drug use?(Required)

Yes

Have you ever had a drink or drug in the morning to get rid of a hangover?(Required)

Yes

Do you have, or ever had, any financial, legal, or health problems due to alcohol/drug use(Required)

Yes

Specifically which problems?(Required)

Were you using any drugs at the time of your arrest?(Required)

Yes

Specifically which drugs?(Required)

Frequency of alcohol/drug use:(Required)

Usual quantity of alcohol consumed MONTHLY:(Required)

Do you ever use drugs?(Required)

Yes

Explain drug intake(Required)

Time elapsed since last alcoholic beverage or drug use?(Required)

Do you mix alcohol with drugs?(Required)

Yes

Do you use drugs instead of alcohol?(Required)

Yes

Has your alcohol/drug use changed since your arrest?(Required)

Yes

Explain how it's changed(Required)

Any family history of addiction / alcoholism?(Required)

Yes

Whom?(Required)

Why did the police stop you?(Required)

Was your arrest justified?(Required)

Yes

Tell us why or why not:(Required)

What was your blood alcohol level at time of arrest?(Required)

e.g. 0.000

Legal Status

Are you on parole or probation?(Required)

Yes

Have you ever been incarcerated?(Required)

Yes

For how many months?(Required)

What was the incarceration for?(Required)

Are you currently attending any other court ordered programs?(Required)

Yes

Which court ordered program?(Required)

Medical Background

Your Health:(Required)

Excellent

Good

Fair

Poor

Are you taking any prescribed medication(s) on a regular basis for a physical problem?(Required)

Yes

Which prescribed medications?(Required)

Medications at time of arrest:(Required)

Enter "none" if applicable, otherwise please be specific

Do you receive a pension for physical disability?(Required)

Yes

Have you ever been treated for Alcohol Abuse?(Required)

Yes

Alcohol Abuse - TREATMENT: How many times?

Please enter a number from 0 to 10.

Alcohol Abuse - DETOX ONLY: How many times?

Please enter a number from 0 to 10.

Please provide all dates for Alcohol Treatment or Detox

e.g. 2006, 2011-2013, 2024

Have you ever been treated for Drug Abuse?(Required)

Yes

Drug Abuse - TREATMENT: How many times?

Please enter a number from 0 to 10.

Drug Abuse - DETOX ONLY: How many times?

Please enter a number from 0 to 10.

Please provide all dates for Drug Treatment or Detox

e.g. 2006, 2011-2013, 2024

Personal Usage History

Your Alcohol Usage(Required)

Abstaining

Social Drinker

Potential Problem Drinker

Alcoholic

How long have you been abstaining?(Required)

Your Drug Usage(Required)

Clean

No Drug Problem

Potential Drug Problem

Addict

How long have you been clean?(Required)

Your Alcohol Use:(Required)

Any use at all

Use to intoxication

How many years have you used alcohol?(Required)

Use numbers only

Other Substances

Other Substances Used (Check all that apply)

Heroin - How many years?(Required)

Please enter a number greater than or equal to 0.

Heroin - Current Use?(Required)

Yes

Heroin - Route of Administration

Swallow

Snort

Inject

Smoke

Methadone/Suboxone - How many years?(Required)

Please enter a number greater than or equal to 0.

Methadone/Suboxone - Current Use?(Required)

Yes

Methodone/Suboxone - Route of Administration

Swallow

Snort

Inject

Smoke

Other Opiates/Analgesics- How many years?(Required)

Please enter a number greater than or equal to 0.

Other Opiates/Analgesics - Current Use?(Required)

Yes

Other Opiates/Analgesics - Route of Administration

Swallow

Snort

Inject

Smoke

Barbiturates/Benzodiazepines- How many years?(Required)

Please enter a number greater than or equal to 0.

Barbiturates/Benzodiazepines - Current Use?(Required)

Yes

Barbiturates/Benzodiazepines - Route of Administration

Swallow

Snort

Inject

Smoke

Sedatives/Tranquilizers - How many years?(Required)

Please enter a number greater than or equal to 0.

Sedatives/Tranquilizers - Current Use?(Required)

Yes

Sedatives/Tranquilizers - Route of Administration

Swallow

Snort

Inject

Smoke

Cocaine - How many years?(Required)

Please enter a number greater than or equal to 0.

Cocaine - Current Use?(Required)

Yes

Cocaine - Route of Administration

Swallow

Snort

Inject

Smoke

Amphetamines/Methamphetamines - How many years?(Required)

Please enter a number greater than or equal to 0.

Amphetamines/Methamphetamines - Current Use?(Required)

Yes

Amphetamines/Methamphetamines - Route of Administration

Swallow

Snort

Inject

Smoke

Cannabis - How many years?(Required)

Please enter a number greater than or equal to 0.

Cannabis - Current Use?(Required)

Yes

Cannabis - Route of Administration

Swallow

Snort

Inject

Smoke

Hallucinogens - How many years?(Required)

Please enter a number greater than or equal to 0.

Hallucinogens - Current Use?(Required)

Yes

Hallucinogens - Route of Administration

Swallow

Snort

Inject

Smoke

Inhalants - How many years?(Required)

Please enter a number greater than or equal to 0.

Inhalants - Current Use?(Required)

Yes

Inhalants - Route of Administration

Swallow

Snort

Inject

Smoke

Have you ever continued drinking/using more than you intended?(Required)

Yes

What is your attitude toward this program?(Required)

Type of alcohol/drug preferred:(Required)

At what age did you first drink alcohol/use drugs?(Required)

Use numbers only

At what age did you begin drinking/using regularly?(Required)

Use numbers only

Do you think your behavior changes when you've been drinking/using?(Required)

Yes

Please describe how your behavior changed.(Required)

Is alcohol and/or drugs a part of your social life?(Required)

Yes

How much do you spend on alcohol and/or drugs?(Required)

Is that weekly or monthly?(Required)

Weekly

Monthly

When you are actually drinking/using, what is the most positive or desirable effect of alcohol/drugs?(Required)

What particular situations, set of events, inner thoughts or emotional feelings, if any, would likely make you feel like drinking/using?(Required)

Employment Information

List all current jobs

Company Name(Required)

If not applicable, please enter None.

Occupation/Position(Required)

If not applicable, please enter None.

Company Name

Occupation/Position

Total Income:(Required)

Hourly, Monthly, Annually?(Required)

Hourly

Monthly

Annually

Are you employed(Required)

Part Time

Full Time

What days do you work? (Check all that apply)

Sunday

What days do you work? (Check all that apply)

Monday

What days do you work? (Check all that apply)

Tuesday

What days do you work? (Check all that apply)

Wednesday

What days do you work? (Check all that apply)

Thursday

What days do you work? (Check all that apply)

Friday

What days do you work? (Check all that apply)

Saturday

What days do you work? (Check all that apply)

I do not work

What hours do you work?(Required)

Enter hours worked, or NONE if you do not work

Are you bilingual? (including reading, writing, understanding and speaking)(Required)

Yes

Do you have problems with reading or writing?(Required)

Yes

Which One(s)?(Required)

Do you have any previous DUI's?(Required)

Yes

WHEN was the previous DUI?(Required)

WHERE was the previous DUI?(Required)

Have you ever attended another Drinking Driver Program?(Required)

Yes

WHEN was that DUI Program?(Required)

During the past year, what was your major source of income? (Check all that applies):(Required)

Earned from employment/job

During the past year, what was your major source of income? (Check all that applies):

Unemployment Compensation

During the past year, what was your major source of income? (Check all that applies):

VA Benefits

During the past year, what was your major source of income? (Check all that applies):

Welfare/SSI/Gov't Assistance

During the past year, what was your major source of income? (Check all that applies):

Soc. Sec. and/or retirement benefits

During the past year, what was your major source of income? (Check all that applies):

Income property/Investments

During the past year, what was your major source of income? (Check all that applies):

Allowance/Alimony/loans from family or others

During the past year, what was your major source of income? (Check all that applies):

Other

If income includes "other", please specify source.(Required)

Additional Information

Highest Level of Education:(Required)

8th Grade or Less

Some High School

High School Graduate

Some College

College Graduate

What grade did you complete in High School?(Required)

Ethnic Background(Required)

White/Caucasian

Hispanic

Asian or Pacific Islander

American Indian

African/American (Black)

Other

Home: Who do you live with?(Required)

Please specify "Other" that you live with(Required)

Do you:(Required)

Rent

Own

Other

Please specify "Other"(Required)

Employment Status(Required)

Please specify "Other"(Required)

Please read all Policies & Procedures below and sign at the bottom:

ALERT PROGRAM, Inc.

Remote Client Services (RCS) | Policies & Procedures

Attendance Policies:

Our RCS attendance policies are intended provide rules and guidance for our clients. Your cooperation is a requirement in order to participate in our program. You hereby acknowledge that you have a basic understanding of the Zoom Communication Platform so as to participate in our Remote Client Services.

Instructions:

Your Program is conducted in two different phases. You may not have the same class day & time for your second phase.
It is strongly recommended that you be in the Zoom waiting room 15 minutes before your scheduled class time. BE READY FOR CLASS & FRONT OF YOUR CAMERA WITH YOUR FULL NAME VISIBLE.
No iPhones or Android smartphones are permitted – you must have a desktop, laptop, or tablet to participate in the Zoom virtual meetings.
Please be patient until all participants have assembled in the Waiting Room and we will admit you to the class session.
Make sure that you're alone and in a private area. No public spaces, walking, exercising, not be in (or driving) a motor vehicle, etc.
There must be no distractions while you attend class – including getting up and walking around! No pets allowed – they can be a distraction.
No smoking, no eating, or doing other tasks. Sit upright, NOT lying down. Use proper lighting and you must be visible at all times (otherwise the counselor will remove you from the class and you will be marked with an absence).
Your camera must always be turned on and facing you for the full session. No false or blurred backgrounds allowed.
If there is a question regarding your Zoom invite, please check your junk/spam folder first before emailing us.
If you get disconnected, please return to your email invite for this meeting and connect again, the counselor will re-admit you to the class session. If the Alert Program loses connection, you will be returned to the Zoom waiting room. Please be patient, we’ll let you back in as soon possible!
It is mandatory that clients attend Alcohol Anonymous meetings in addition to your Program. You must submit your AA card with proof of attendance for each meeting. Once completed, you can drop your AA cards in person, or mail them to our office. They MUST be received 72 hours prior to your final RCS class session. (Please do not write on your signature card; have the secretary/leader at the AA meeting fill out & sign the card.) It is your responsibility to obtain the proof that you attended and deliver it to the Alert Program office.

Pre-Conviction Clients:

If you are entering the RCS Program as a pre-conviction client, you must do the following:

Notify the court that you are already enrolled in a DUI Program
Follow the instructions set forth by the court which may include:

a. reporting to a county agency or court liaison (this is a required step – a MUST) and/or

b. adjustment to the required length of program
Report the above information to us the Alert Program, upon the outcome of your court conviction.
If you do not follow the necessary procedure nor provide us with the required information, your case could go to warrant, and/or affect the issuance or re-issuance of your driver's license.

Notifications:

If your physical address, email address or phone number changes, please notify us immediately, or you may not receive the RCS invites, or your final documentation will be in error.

Notice: We are not responsible for documentation errors if we are not notified.

House Arrest / Electronic Monitoring:

You will need to bring our contract indicating your assigned class day and time when you report so they will allow you to attend the program + AA’s.

RCS (Virtual Class) Violations:

No sleeping during the class! If our counselor notices you asleep, a screenshot will be taken of the incident, you will be removed and you will receive an absence. If it is your last absence, you may be terminated from the program.
Any notice by our Counselor that you are drinking (other than water) eating, or otherwise not paying attention at all times, will result in a screenshot of the incident, you will be removed and you will receive an absence. If it is your last absence, you will be terminated from the program.

Payments:

All Invoices will be sent to RCS Clients via the email they have provided above. The following payment policies are for RCS Clients:

Past Due accounts are subject to suspension or termination.
You must be Paid in Full by your Final session for us to file the completion.

Cell Phones or any electronic devices: Are prohibited in the building. Client will be excluded from class with an absence for the day if the cellular phone rings, vibrates or is seen in the program. (If it is your last absence you will be terminated from the program.)

Holidays:

The Alert Program RCS classes will be closed for the following Federal Holidays:

New Year's Day
Martin Luther King Day
President's Day
Memorial Day
4th of July
Labor Day
Thanksgiving
Christmas Eve & Christmas Day

Dress Code Policy:

It is Alert Program policy that appearance and clothing should be neat, clean, and not in need of repair. Attire is a reflection of someone attending education classes and should be appropriate and not at all offensive. Attire that is assessed as inappropriate will be left to the discretion of the counselor conducting the RCS class.

The following is a partial list of unacceptable attire while receiving services at our facility:

Clothing may not reflect nudity, alcohol, drugs, inappropriate or offensive language or symbols
No attire that unnecessarily exposes or reveals the chest, midriff or stomach
Brassieres must be worn – bathing suit tops and sarongs are not permitted
No see-through fabric or otherwise revealing attire, i.e. tube tops, etc.
Hooded Sweatshirts (hoodies) are permitted, but no hoods up during the RCS class
Visible tattoos that are deemed offensive or unprofessional by a reasonable person
No sunglasses

Cell Phone Policy:

I understand and acknowledge that this is a CONFIDENTIAL PROGRAM. As such, there are NO CELL PHONES ALLOWED AT ANY TIME - including, but not limited to: Electronic watches, Smartphones, iPods/Pads and tablets are PROHIBITED at all times. You will be removed and will receive an absence if your cell phone rings, vibrates or is seen during the RCS Class.

The Watson Notice:

I understand and acknowledge that alcohol and/or drugs impair my ability to drive, and I additionally understand the dangerous consequences of drinking and or using drugs and driving. If I choose to ignore this warning, and drive while under the influence of alcohol/drugs or both, and someone is killed, I understand I may be charged with vehicular manslaughter or murder, the elements of malice in a charge of murder may be implied because I have knowledge of the danger of the conduct and the risk that such conduct poses to the public. (People vs. Watson 30 Cal 3d. 290,179 Cal Rptr 43).

Consent for the Release of Information:

I hereby authorize ALERT PROGRAM, INC. to disclose to the Referring Court, Judicial System, Riverside County Court Liaison/Referral Agency, DHCS, DMV, Probation or Parole Department (if applicable), DPSS (if applicable), a report on my program participation. The need for such disclosure is to provide them with the progress, attendance, attitude and lifestyle changes, as well as admission, completion or termination of the program.

I understand that my records are protected under Federal Confidentiality Regulations and cannot (Section 42 USC 290DD-3) and cannot be disclosed without my written consent unless otherwise provided for in these regulations.

I also understand that I can revoke this consent at any time unless to the extent of the action has been taken in reliance on it (e.g. probation, parole, etc.) and that in any event, this consent automatically expires as described below:

This authorization will be valid for the duration of the participant's participation in the program and shall expire ten (10) years after completion, termination or transfer from the program.

Confidentiality Statement:

I hereby understand, acknowledge and agree to abide by the Federal Regulations on Confidentiality regarding Alcohol and Drug Treatment: 1.) The identity of all clients is guaranteed confidential. 2.) All information disclosed in group or individual sessions remains confidential and is not to be shared outside of that session. 3.) Personal client records will not be released to any source without proper consents signed by the client.

Entire RCS Enrollment Agreement:

The Undersigned hereby acknowledges that they have read and truthfully completed the Enrollment Questionnaire, read and acknowledged and agreed to its Attendance Policies & Procedures and that they further hereby agree to the terms and conditions set forth herein:

Electronic Signature Consent(Required)

I understand that by signing below, I am electronically signing this document and agree that my electronic signature is the legal equivalent to my handwritten signature.

E-Signature(Required)

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Date Signed

This field is hidden when viewing the form

IP Address