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The following must be completed and returned to us prior to the Thursday beginning of your program. Print out this form and email once completed to canprograms@ or you can also fax it to: 866-627-9073. All fields must be completed. Please print.First Name___________________ ______Last name__________________________________________Name of your court_____________________________________________________________________Case number (this has year of your charge and the letters TRC in it)______________________________Name of Judge____________________________________ Program date _________________________Name of probation officer ( if you do not have one mark N/A)___________________________________Please identify below if you took a chemical test that was used in your charge. This is only testing for blood alcohol levels or the presence of other drugs. For each yes provide the number you were given (for example BAC yes of .10). If you did not get an alcohol test then list the substance you were tested for (for example Urine test yes +THC). Breath test (BAC) Y N Result_______Urine test Y N Result________ Blood test Y N Result_______Did you refuse testing? Y N Is this your first impaired driving charge( OVI, Reckless Op or Physical Control)? Y N How many prior charges? ____ Years of prior offenses___________________________Did you complete an alcohol/drug assessment after this offense? Y N Where___________________Is there a family history of substance abuse in your family? Y N List any medical problems you are currently receiving treatment for___________________________________________________________________________________Medications you currently take____________________________________________________________In your lifetime have you felt you should cut down on drinking or drug use? Y NIn your lifetime have people annoyed you by criticizing your drinking or drug use? Y NIn your lifetime have you ever felt bad or guilty about drinking or drug use? Y NIn your lifetime have you ever had a drink or drug first thing in the morning (eye opener) to steady your nerves or get rid of a hangover? Y N ................
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