Client Face Sheet (Level 2 Education)
Full Name EXACTLY as it appears on your Driver's License
Nickname/ Preferred Name
Date of Birth:
Street Address Line 2
State / Province
Postal / Zip Code
County where you live:
Cell Phone Number
Please enter a valid phone number. You will receive your ZOOM LINK by text and email.
Cell phone Carrier Sprint, T-Mobile, etc:
Did your DUI happen in Colorado?
County where your DUI happened:
Date of last DUI/DWAI?
Including this one, how many DUI/ DWAI’s have you had?
Was your DUI related to Alcohol, Marijuana, or Prescription Medication?
Did you do a breathalyzer, blood test or REFUSE?
What was your BAC level?
Have you been assigned a Probation Officer? If yes, what is their Name:
Probation Officer Email:
Do you have an attorney/ public defender? If yes, what is their Name:
Attorney/ Public Defender Email:
If currently doing UA’s (Drug Testing) for probation/ pre-trial? What is your UA ID#?
Driver’s License #:
How did you hear about us?
For Level 2 EDUCATION, which class time do you prefer (ONLINE VIA ZOOM)?
PAY PER CLASS FEES:
Class fee is $30/ week
Today’s fee will
include the Intake ($75) and First Class ($30) = $105
PAY IN FULL FOR 10% DISCOUNT:
10% Discount offered if balance PAID IN FULL at the time of the intake/
applies to class fee only
TOTAL PROGRAM FEE: $360 (12 classes at $30/class) + $75 intake = $435
$324 (12 classes at $27/class)+ $75 intake =
$399 WITH DISCOUNT
Do you want to PAY PER CLASS or PAY IN FULL today?
PAY PER CLASS ($30/ class; $105)
PAY IN FULL ($27/ class; $399)
PLEASE PRESS SUBMIT BELOW; You will be directed to the:
#2 TELEHEALTH CONSENT FORM
Type a question
Should be Empty: