COUNTY# ________________________ Referral Date ____________________________ Time In: ___________

Today’s Date: ______________________ Violation Date ___________________________ Time Out: __________

California Driver’s License # or ID # ___________________________ or CA DMV X#______________________
Court ____________________________ Case # _______________________________ BAC _________________

Full Name ____________________________________________________________________________________

Last Name First Name Middle Name
Sex ___________ Age ____________ Birth Date ___________________ Height _________ Weight ___________
Ethnicity _______________________ Religious Preference ________________

Current Address ___________________________________________________ Marital Status ________________

Number and Street Name (Apt or Suite #)

___________________________________________________ Living With _________________

City State Zip Code
Selectcondo,
Place of Residence (circle one) house, one apartment, hotel, motel, mobile home, homeless

Home Phone ( ______ ) _____________________________ Cell Phone ( ______ ) _________________________

In Case of Emergency Notify _________________________ Phone # ( ________ ) _________________________

Select one
# of Times You’ve Been Married _______ Has your spouse ever complained about your drinking? _____________

Children: How many sons? ______ Ages _________________ How many daughters? _____ Ages_____________

Education Status: (Circle highest completed) Elementary Select

4 5 one6 7 8 High School 9Select
10 one
11 12

Name of High School _________________________________________ Year Graduated ____________________

Name of Trade School _________________________________________ Year Graduated ____________________

Name of College/University ____________________________________ Year Graduated____________________

Have you served time in the military? ______

Select If yes, what branch and how long? ___________________________

During the past year, what was your major source of income? (Check ALL that apply)
____ Earned from employment ____ Allowance/loans from family or others ____ Unemployment compensation
____ VA Benefits ____ Social Security/Retirement Benefits ____ Welfare (Type of Aid) ___________________
____ Other (Specify) _________________________ Total Monthly Income ________________

Employer: ___________________________ Type of Business ____________________ Position ______________

Address (city and state only) _______________________________ How long employed? ____________________
I ________________________________ am requesting a DL107 Proof of Enrollment in order to apply for a
restricted license.

Signature _______________________________________ Date ________________________

I ________________________________ am not requesting a DL107 Proof of Enrollment because I do not wish to

apply for a restricted driver’s license.

Signature _______________________________________ Date ________________________

How many times have you driven under the influence of alcohol/ and or drugs? ____________

How many times have you been in a car accident while driving under the influence of alcohol/and or drugs? ______

How many times have you been arrested for Driving Under the Influence of alcohol or drugs in your life? _______

How many times have you been arrested for Reckless Driving in your life? ____________

How many times have you been arrested because of illegal drugs? ___________________

Have you ever attended another Court Ordered Program? Yes _____ No ______ If yes, what year (s) ___________

Where _________________________ For how long? _____________

Where _________________________ For how long? _____________

Where _________________________ For how long? _____________

I usually drink, or my drug of choice is: __________________________

____ beer ____ wine ____ malt liquor ____ wine coolers ____ mixed drinks ____ vodka

____ bourbon ____ rum ____ tequila ____ whiskey ____ gin ____ scotch

____ cognac ____ brandy ____ champagne

On average, I usually spend about what amount per month on alcohol? $ _________

On average, I usually spend about what amount per month on drugs? $ ___________

My family complains about my drinking or drug use ____ occasionally _____ almost always _____ never

Their usual reaction is: _____ clams up _____ nags _____ complains about money spent on alcohol/drugs

_____ makes accusations _____ dislikes drinking/using buddies

_____ blames my job _____ all of the above

Father/Male guardian’s involvement with alcohol? A. none B. experimental C. occasional D. daily

His involvement with other drugs? A. none B. experimental C. occasional D. daily

Mother/Female guardian’s involvement with alcohol? A. none B. experimental C. occasional D. daily

Her involvement with other drugs? A. none B. experimental C. occasional D. daily

Are any your aunts, uncles, brothers, sisters, cousins or grandparents alcoholics or addicts? Yes _____
Select oneNo _____

If yes, who? ________________________________________________________________________________

Whom do you know who drinks excessively or has a drinking problem, but you don’t feel to be an alcoholic?

____ friend ____ uncle/aunt ____ father ____sister/brother ____ grandma/grandpa ____ cousin

Think of the 12 hours before your arrest or citation. Read the following questions and circle the letter of the
appropriate answer. For some questions you may have to circle more than one answer.
Select one
1. At approximately what time did you start drinking or using? _______ am/pm
Select one
At approximately what time did you stop drinking or using? _______ am/pm

2. Where did you drink or use? A. Bar B. Home C. Friend’s home D. Office E. Automobile
F. Other
3. With whom did you drink or use? A. Husband/Wife B. Friends C. Alone D. Other relatives
F. Strangers
4. What did you drink or use? A. Beer B. Wine C. Malt liquor D. Wine coolers E. Cocktails/liquor

F. Pot G. Speed H. Ecstasy I. Heroin J. Cocaine K. Pills L. Other _____________________

5. About how much did you drink or use during this time? A. 1-2 drinks B. 3-4 drinks C. 5-6 drinks

D. 7-10 drinks E. 11 or more drinks F. Or I used _____________________ amount of drugs

6. Why did the police stop you? A. Traffic violation B. Automobile defect C. Accident D. Other

7. When were you arrested? A. Morning: 8am-noon B. Afternoon: noon-4pm C. Evening: 4pm-8pm

D. Late evening: 8pm-midnight E. Early morning: midnight-8am

8. What was the occasion for drinking or using? A. Celebration B. After Work C. Tragedy D. Business
E. None
9. Why did you drink or use? A. Lonely B. Angry C. Escape D. Upset E. No reason F. Elated
10. How much are you to blame for the events that led to your arrest?

A. Not at all to blame B. Slightly to blame C. Somewhat to blame D. Mostly to blame

E. Entirely to blame

11. Do you feel it was fair to be arrested?

A. Not at all fair B. Slightly fair C. Somewhat far D. Mostly fair E. Entirely fair

12. What do you believe are your chances of being arrested again on the same charge within the next year?

A. No chance B. Somewhat easy C. Somewhat difficult D. Difficult E. Very difficult

13. How difficult will it be for you to change your behavior that led to your arrest?

A. No chance B. Somewhat easy C. Somewhat difficult D. Difficult E. Very difficult

14. How valuable do you feel this course will be for you?

A. Not at all valuable B. Slightly valuable C. Fairly valuable D. Valuable E. Extremely valuable

15. How often do you have a drink containing alcohol?

A. Never B. Monthly or less C. 2-4 times a month D. 2-3x a week E. 4 or more times a week

16. How many drinks containing alcohol do you have on a typical day when you are drinking?

A. None B. 1-2 C. 3-4 D. 5-6 E. 7-9 F. 10 or more

17. How often do you get drunk?

A. Never B. Less than monthly C. Monthly D. Weekly E. Daily or almost daily

18. How often do you use illegal drugs?

A. Never B. Less than monthly C. Monthly D. Weekly E. Daily or almost daily

19. What illegal drugs have you used in the past year? ____________________________________________
Select one
20. Has anyone ever suggested that you may have an alcohol or other drug problem? ____________________

If yes, who? __________________________________________

Select one
Have you ever thought that you may have an alcohol or other drug problem? _______________________

If yes, when? _________________________________________

Select one
21. Is there anything that would prevent you from completing this course?

If so, what? __________________________________________

 Prior Criminal Record
Charge/Offense Arrest Date City Arrested In Disposition of case

Please complete this information to the best of your ability and remember that this information is confidential, your
rights as a participant are protected by law. The information we are requesting is an important part of this program.
Help us help you. Your cooperation is greatly appreciated.
Age First Used/ Age Last Used/ If using now, how much? Do you consider
With Whom With Whom Per Day Per Week you use a problem?
Alcohol

Marijuana

Speed

Cocaine-Crack

Ecstasy

LSD/Mescaline

Mushrooms

Heroin-Opiates

PCP

Barbiturates

Inhalants

Other

Please circle “yes” if you have had any of the following

High blood pressure Yes No Loss of appetite Yes No
Diabetes Yes No Difficulty in breathing Yes No
Hepatitis Yes No Sleeplessness Yes No
Nervousness Yes No Swelling of ankles Yes No
Depression Yes No Increase of frequency of urination Yes No
Paranoia Yes No Vomiting of blood Yes No
Are you currently under the care of a physician? ____________
Select one

Are you presently taking any prescribed medication? _________

Select one If yes, please list medications

_________________________________________________________________________________
 Name: _______________________________ Date: ________________________

The Michigan Alcoholism Screening Test (MAST)

Please circle Yes or No for each item as it applies to you.
1. Do you feel you are a normal drinker? (By normal we mean you drink less Yes No
than or as much as most other people.)
2. Have you ever awakened in the morning after some drinking the night Yes No
before and found that you could not remember a part of the evening?
3. Does your wife, husband, a parent, or other near relative ever worry or Yes No
complain about your drinking?

4. Can you stop drinking without a struggle after one or two drinks? Yes No
5. Do you ever feel guilty about your drinking? Yes No
6. Do friends or relatives think you are a normal drinker? Yes No
7. Are you able to stop drinking when you want to? Yes No
8. Have you ever attended a meeting of Alcoholics Anonymous (AA)? Yes No
9. Have you gotten into physical fights when drinking? Yes No
10. Has your drinking ever created problems between you and your wife, Yes No
husband, a parent, or other relative?
11. Has your wife, husband (or other family members) ever gone to anyone for Yes No
help about your drinking?
12. Have you ever lost friends because of drinking? Yes No
13. Have you ever gotten into trouble at work or school because of drinking? Yes No
14. Have you ever lost a job because of drinking? Yes No
15. Have you ever neglected your obligations, your family, or your work for Yes No
two or more days in a row because you were drinking?
16. Do you drink before noon fairly often? Yes No
17. Have you ever been told you have liver trouble? Cirrhosis? Yes No
18. After heavy drinking have you ever had Delirium Tremens (D.T.s) or severe Yes No
shaking, or heard voices, or seen things that really were not there?
19. Have you ever gone to anyone for help about your drinking? Yes No
20. Have you ever been in a hospital because of drinking? Yes No
21. Have you ever been a patient in a psychiatric hospital or on a psychiatric
ward of a general hospital where drinking was part of the problem that Yes No
resulted in hospitalization?
22. Have you ever been seen at a psychiatric or mental health clinic or gone to
any doctor, social worker, or clergyman for help with an emotional Yes No
problem, where drinking was part of the problem?
23. Have you ever been arrested for drunk driving, driving while intoxicated, or
driving under the influence of alcoholic beverages? Yes No
(If YES, how many times? _____ )
24. Have you ever been arrested, or taken into custody even for a few hours
because of other drunk behavior? Yes No
(If YES, how many times? _____ )

Counselor’s Signature: ________________________________________ Date: ______________________

 CONFIDENTIALITY
The presence and the treatment of participants at “A Better Community” Counseling
Program LLC/A.B.C. Counseling Program are protected by the following mandates:

FEDERAL PRIVACY ACT (42 CFR-2) 1975 & THE CALIFORNIA MENTAL HEALTH SERVICES ACT

The participant’s right to confidentiality is set forth in the above-named statutes. Disclosures
of ANY information which pertains to participants at “A Better Community” Counseling
Program LLC/A.B.C. Counseling Program subjects the individual to penalties (fine and/or
custody) as set forth in these laws I certify that I UNDERSTAND each participant’s right to
confidentiality MUST be PROTECTED.

Participant Signature _________________________________ Date___________

Witness Signature ___________________________________ Date___________

“A Better Community” Counseling Program LLC/A.B.C. Counseling Program is in compliance of

the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, and the Rehabilitation
Act of 1973. “A Better Community” Counseling Program LLC/A.B.C. Counseling Program does not
discriminate in matters of employment or admission to educate programs and activities because of
race, color, natural origin, marital status, sex, religion, age, handicap, or AIDS.
 CONSENT FOR RELEASE OF
INFORMATION

I, authorize “A Better Community” Counseling Program LLC/A.B.C. Counseling Program to

disclose to the Judicial system, Riverside University Health Systems – Behavioral Health –
Substance Abuse Prevention and Treatment Programs (RUHS-BH-SAPT), the Department of
Health Care Services (DHCS), the California Department of Motor Vehicles (DMV), Riverside
County Probation Department (if applicable), State Parole (if applicable), the Department of
Public Social Services (DPSS) (if applicable) a state report on program participation. The purpose
or need for such disclosure is to provide them with program attendance, progress, attitude, and
lifestyle change. I understand that my records are protected under the:
FEDERAL CONFIDENTIALITY REGULATIONS (SECTION 42 USC 290DD-3)
and cannot be disclosed without my written consent unless otherwise provided for in the
regulations.
I also understand that I may revoke this consent at any time except to the extent that action has
been taken in reliance on it (e.g. probation, parole, etc.) and that in any event of this consent expires
automatically as described below. This authorization will be valid for the duration of participant’s
participation in the program and shall expire ten (10) years after completion, termination, or transfer
from the program. I authorize a representative from Riverside University Health Systems –
Behavioral Health – Substance Abuse Prevention and Treatment Programs (RUHS-BH-SAPT) and
the Department of Health Care Services (DHCS) to attend and observe any session.

Participant Signature______________________________________ Date____________________

Witness Signature________________________________________ Date____________________

 A Better Community Counseling Program LLC
CONSENT FOR URINALYSIS/BREATHALYZER TESTING

I, ____________________________________________ do give permission to “A Better

Community” Counseling Program LLC/A.B.C. Counseling Program to drug/alcohol (urinalysis

and breathalyzer) test me if any program staff member suspects me of being under the influence of

any amount of alcohol or drugs while attending program services or activities or while being on the

program premises. Medication prescribed by a licensed physician and used in accordance with

the prescription does not apply to this regulation unless the participant is unable to participate in

program services due to the effects of the medication (e.g. falling asleep, unable to pay attention,

etc.). I understand that any “POSITIVE” or “DIRTY” urinalysis test will cost me ten ($10.00)

which is due and payable at my next scheduled appointment.

Participant Signature _________________________________ Date_____________

Witness Signature____________________________________ Date_____________

 Watson Advisement Notice

You are hereby advised that being under the influence of alcohol or drugs or both, impairs
your ability to safely operate a moto vehicle. Therefore, it is extremely dangerous to
human life to drive while under the influence of alcohol or drugs, or both. If you continue
to drive while under the influence of alcohol or drugs, or both, and as a result of that
driving, someone is killed, you can be charged with murder.

I acknowledge that I have been given a copy of the California Watson Advisement Murder

Rule.

Participant Signature__________________________________________ Date____________

Witness Signature____________________________________________ Date_____________

California DUI Murder a.k.a. The Watson Murder Rule
Posted on May 26, 2010 by attorney Gabriel Dorman, Provide IDP Consumer a copy of this document.
Place signed and dated Acknowledgement of Receipt in consumer’s chart.

In California, a DUI resulting in the death of another human being is known as a “Watson Murder.” The
“Watson Murder” or “Watson Murder Rule” originated with the case of People v Watson, in which a
multiple DUI offender’s prior convictions were used to prosecuted him for second-degree murder under the
legal theory of “implied malice.”

“Implied Malice” second-degree murder can best be summarized as follows: “I know what I am doing is
dangerous to human life, but I don’t care, I am going to do it anyway!”

In 1981 the California Supreme Court, in the landmark case of People v. Watson, held that someone who
causes a fatal accident as a result of driving drunk can be found guilt of second-degree murder based on a
theory of “implied malice.” As a result, nearly all courts in California require the signing of a “Watson
Advisement” as part of DUI sentencing as a way to make prosecution of a potential subsequent second
degree murder case by DUI easier to prosecute.

“Watson Murder” prosecutions are generally, but not exclusively, applied to individuals with prior DUI
convictions. An individual’s prior conviction(s) often makes it easier to prove “implied malice” because
their prior conviction puts them on notice of the inherent dangers of drinking and driving. In almost all
cases, the person has already attended alcohol educations classes where they learned about the dangers of
drinking and driving. As such, what the person may not have known the first time they got a DUI, cannot be
said for the second or subsequent DUI. Prosecutors will also use prior attendance at DUI schools to prove
that the defendant was expressly aware of the dangers of driving drunk including the potential for killing
someone.

As a matter of fact, in an effort to make future Watson Murder prosecutions easier, all California courts,
including all Los Angeles and Orange County DUI courts, require a defendant to sign a waiver advising
them of the dangers of DUI and the potential consequences if they do it again and hit and kill someone in
the process. The advisement is referred to as “The Watson Advisement” which states as follows:

I understand that being under the influence of alcohol or drugs, or both, impairs my ability to safely
operate a motor vehicle. Therefore, it is extremely dangerous to human life to drive while under the
influence of alcohol or drugs, or both. If I continue to drive while under the influence of alcohol or
drugs, or both, and as a result of my driving, someone is killed, I can be charged with murder.

This way, if that person happens to drink and drive again, and in the process, hits and kills someone with
their car, there is a signed notice on file with the court acknowledging they knew it was dangerous but did it
anyway…implied malice has been established for purposes of a “Watson Murder.”
 Assessment
Date of Interview: ___________

General Profile

Client Name: ___________________________________

Gender: Male______ Female_______ Age:________

Employment Status
1. Education completed: Yrs______ Mos______
2. How long was your longest full-time job? Yrs_____ Mos______
3. Usual or last occupation
Specify:_____________________________________
4. Usual employment pattern, past three years?
☐Full Time ☐Retired/disabled
☐Part Time (regular hours) ☐Unemployed
☐Part Time (irregular, day work) ☐In a controlled environment
☐Student ☐Unknown
☐Service

Family Social Relationships

1. Marital status? ☐Married ☐Remarried ☐Widowed ☐Divorced ☐Never Married
2. How long have you been in this marital status _____ Yrs _____ Mos
3. Are you satisfied with this situation? ☐No ☐Indifferent ☐Yes
Do you live with anyone who:
4. Has an alcohol problem? ☐Yes ☐No
5. Has an illicit drug problem? ☐Yes ☐No
6. Uses non-prescribed drugs? ☐Yes ☐No

Family Substance Abuse History

1. Any history of alcohol or drug abuse in your family? ☐Yes ☐No
Father Mother Grandparent Sibling Aunt/Uncle Child
2. How long did they abuse? ______ Yrs ______ Mos
3. Did they seek treatment for their substance use? Yes No
4. What is the outcome of their status? Recovery Unknown

Medical Status
1. Do you have any chronic medical problems which continue to interfere with your life? Yes No one
Select

If yes, specify: ________________________________________________________________

2. Are you taking any prescribed medication on a regular basis for a physical problem? Select
Yes Noone
If yes, specify: ________________________________________________________________
3. Do you receive a pension for physical disability? Yes No one
Select
4. Have you or are you taking any medication that is not prescribed for you? Select
Yes Noone
If yes, specify: ________________________________________________________________
 Legal Status
1. Was this admission prompted or suggested by the criminal justice system
(judge, probation/parole officer, etc.)? ☐Yes ☐No
2. Are you on probation or parole? ☐Yes ☐No
How many times in your life have you been charged with the following?
3. Disorderly conduct, vagrancy, public intoxication? _______
4. Driving while intoxicated? ________
5. Major driving violations (reckless driving, speeding, no license, etc.)? _____
6. How many months were you incarcerated in your life? ______ months
7. How long was your last incarceration? ______ months
8. What was it for? _________________
9. Are you presently awaiting charges, trial, or sentence? ☐Yes ☐No

Drug/Alcohol Use

DRINKING PATTERNS RELATED PHYSICAL PROBLEMS

Daily, AM and/or on the job Yes____ No____ Blackouts Yes____ No____

Weekday evening drinking Yes____ No____ Hangovers Yes____ No____
Stop off after work Yes____ No____ Passing Out Yes____ No____
Weekends Yes____ No____ Liver Problems Yes____ No____
Occasional Heavy Yes____ No____ DT’s Yes____ No____

How many times have you been treated for :

Treatment Detox Only
Alcohol Abuse _____ _____
Drug Abuse _____ _____

How do you see yourself in relationship to alcohol/drugs:

ALCOHOL DRUGS

___ Abstaining (how long ____)

___ Social Drinker ___ No Drug Problem
___ Potential Problem Drinker ___ Potential Drug Problem
___ Alcoholic ___Drug Problem
___ In Recovery (how long ____) ___ In Recovery (how long ____)
Substance Years In Current Use Route of Administration
Lifetime (circle Y or N) (e.g. nasal, oral, etc.)
1. Alcohol – any use at all Y N
2. Alcohol – to intoxication Y N
3. Heroin Y N
4. Methadone Y N
5. Other opiates/analgesics Y N
6. Barbiturates Y N
7. Other Sedatives Y N
8. Cocaine Y N
9. Amphetamines Y N
10. Cannabis Y N
11. Hallucinogens Y N
12. Inhalants Y N
13. Use more than one substance Y N Specify:
 COUNSELORS EVALUATION AND RECOMMENDATIONS
-------------------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------
MAST SCORE: ________

Comments:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Counselor recommends:
___ No recommendations ___ AA ___NA ___MA ___Life Ring ___A.C.A. ___ Alanon
___ Detox ___Residential Treatment ___Private Counseling
___ Other:
_____________________________________________________________________________________________
_____________________________________________________________________________________________

This assessment and recommendations has been discussed with me.

Participant’s Signature: ____________________________________________ Date: ________________

Counselor Signature: ______________________________________________ Date: ________________