Thank you for choosing LifeSwitch to administer your alcohol and drug evaluation. Once you submit this form you will be taken to the payment screen. Payment must be received to complete your registration. Within 24 hours you will receive instructions on how to access and electronically sign the State of Georgia's required documents. After completion we will be in touch within one business day to schedule your evaluation.

If at any time you need help with any part of this process please call us at 770-731-2479 or email Jacob, our administration manager at [email protected]

First Name *

Middle Initial

Last Name *

Cell Phone *

Email *

Address *

Apt. #

City *

State *

Zip Code *

Preferred Method of Contact *

Birthdate *

Last 4 of Social *

Drivers License # *

DL State *

Expiration Date *

Marital Status *

Employment Status *

Race *

Education *

Please confirm the following information: ALL REQUIRED*

SECTION 2: LEGAL HISTORY

Total Arrests Lifetime?

Total DUIs Lifetime?

Total DUIs Past 10 Yrs?

Total DUIs Past 5 Yrs?

Total MJ Possession Arrests?

Total Other Drug Poss Arrests, not MJ?

SECTION 3: TREATMENT HISTORY

How Many Treatment Events* Have You Had Lifetime for Alcohol/Drugs

PLEASE NOTE THE NUMBER OF TREATMENT EVENTS YOU HAVE HAD LIFETIME IN EACH CATEGORY

AA/NA meeting

Detox Facility

Intensive Out-Patient

Counseling

In-Patient Rehab 15-60 days

In-Patient 61+ days

* A Treatment event is consecutive time period where you were being treated for substance abuse. If you went to AA meetings for 3 years, that is one event. 60 days in a rehab facility is one event.

Please confirm the following information: ALL REQUIRED*

Are you required to take this evauluation due to DUI?

Yes No

If Yes, who was the agency that arrested you (e.g., Fayette County, Coweta County, Fayetteville Police, Newnan Police, Peachtree City Police, etc.)

What was the month and year of the event that created the need for this evaluation?

Month

Year

Has your case been fully ajudicated in court or do you still have another court date?

Yes No

If not for DUI, briefly describe the reason you are required to have this evaluation completed.

Will you be taking this evaluation in our office ($155) or 100% virtually ($195)? *

IMPORTANT: Court-required evaluations can take 10 to 15 days to complete and the clock doesn't start until you have finished all of your part and we have finished the clinical interview together. Are you facing a deadline that this could impact?

Yes No

If you answered "YES" please come talk to us personally and we always try to accommodate. Sometimes we can and sometimes we can't. But if the consequences of missing the deadline is very consequential, we do have expedited services of 24, 48 and 72 hours for a fee.If you need this, don't forget to indicate that at the bottom of this form.

If you have recieved a DUI, then in addition to this evaluation you will need to take the 20 hour DUI / Risk Reduction Course. LifeSwitch offers this course usually over the weekend live in classroom or from the comfort of your home for the same price.

Have you been assigned a Probation Officer?

Yes No

Officer Name *

PO Phone *

Jurisdiction / Agency *

PO Email *

We will send your evaluation results to your probation officer with a copy to you. If you have an attorney and would like us to send the results to him / her as well, please list them below

Attorney Name

Attorney Phone

Attorney Email

Any additional comments you think we should know, please add below

QUESTIONS?

GA DDS CERTIFIED DRIVING COURSES OFFERED IN LIVE OR VIRTUAL CLASSROOMS

Clinical Evaluation Signup

OFFICE HOURS:

(770) 731-2479