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Phone: [PHONE REDACTED] Patricia A. Schanen Director Douglas County Department of Health and Human Services 1316 N. 14th Street y Superior, WI 54880 MISSION To promote the health, safety, and well-being of individuals and families Health Division Suite 324 Fax [PHONE REDACTED] Human Services Division Suite 400 Fax [PHONE REDACTED] PLEASE TAKE A FEW MINUTES TO READ CAREFULLY: Collateral information must be obtained as part of your Intoxicated Driver Program Assessment or other Assessments being requested by the Department of Transportation. An appropriate collateral source may be: your spouse or significant other, parent, brother/sister, or some one who’s known you for several years such as a close friend. Please complete both release forms and sign. Please return both completed forms with the packet to the clerical staff. One release will be placed in your file; the other will accompany the questionnaire sent to your collateral contact. The collateral contact questionnaire will be mailed by the clerical staff to your chosen contact person, with a self addressed stamped envelope enclosed. You may not look at or handle the questionnaire. The questionnaire must be returned to the assessor prior to your appointment date or the assessment may not be complete. Please do not hesitate to contact this department if you have any questions or concerns. Thank you for your assistance in expediting this process. Best Regards, Dave Longsdorf, MA, IDP-AT Intoxicated Driver Program Coordinator ---PAGE BREAK--- Today’s Date: Client’s Name Collateral Contact: First Last Street Apt City, State Zip Phone Relationship to I am participating in an Intoxicated Driver Program Assessment at Douglas County Department of Health and Human Services. I am authorizing the agency permission to send you this questionnaire as an effort to obtain collateral information related to my alcohol & other drug use. I realize that this information may be included in my file and that all records remain confidential. Your responses will become part of the assessment and may be used as an aid in determining the outcome of the Driver Safety Plan requirements. If you have any questions or prefer to discuss your concerns in person, please do not hesitate to call Douglas County Department of Health and Human Services Intoxicated Driver Program Coordinator. Thank you in advance for your time and input. Sincerely, Client Signature ---PAGE BREAK--- Alcohol &/or Other Drug Use Questionnaire Client’s Name: Person Completing This Form: Relationship to the Client: The information provided may assist in the Intoxicated Driver Program Assessment and with the completion of the Driver Safety Plan recommendations. We urge you to provide the information requested along with any other information that you think might be important using factual information. Your prompt response is appreciated. A self-addressed, stamped envelope is enclosed for your convenience. Please indicate which of these statements best describes the client’s drinking behavior and/or drug using behavior. Frequently Sometimes Never/Unknown The client stays intoxicated/high for several days at a time. The client is preoccupied with having a drink/drugs at inappropriate times. Ex: Lunch, school/family events The client drinks /uses drugs alone. Once client starts drinking /using, it is difficult for them to stop before becoming completely intoxicated/high. Takes a drink/drug first thing when they wake up. The client neglects regular meals when drinking/using. The client would rather buy alcohol or drugs than pay for bills or buy other personal supplies. Ex: rent, food, utilities The client misses events or activities due to their drinking/ drug use. Please explain above listed Check all that apply: What is the problem as you see it? In your opinion, what is the problem as the client sees it? ( ) Alcohol and/or drugs ( ) Alcohol and/or drugs ( ) Financial/ employment ( ) Financial/ employment ( ) Gambling ( ) Gambling ( ) Emotional ( ) Emotional ( ) Family Problems ( ) Family Problems ---PAGE BREAK--- ( ) ( ) Is there a pattern of their alcohol and/or drug usage? (Drinks beer, wine or hard liquor, drinks alone, drinks with others, takes pills such as Valium, sleeping pills, amount, frequency, etc.) List any physical problems, including accidents or injuries that the client has encountered because of the use of alcohol or other Has the client’s use of alcohol or other chemicals affected his or her employment/school or other opportunities? Yes / No Please explain. Has alcohol and/or other drugs affected the client and his or her family financially? Yes / No Please explain. In your honest opinion do you think the client would benefit from going through a treatment program at this time? Why or Why Explain if/how the client’s use of alcohol/drugs has affected your relationship and the relationship with his or her To the best of your knowledge, has the client ever been abusive (verbally, physically or sexually) to you or the client’s family under the influence? If yes*, please ---PAGE BREAK--- Aside from the use of alcohol or other drugs, please describe any other concerns or information that you would like to The information that I disclosed is accurate to the best of my knowledge. Signature Date I understand that not everyone who receives an OWI or an Implied Consent Refusal citation is an alcoholic or other drug addict. That is part of the reason why the intoxicated driver program is required by the Wisconsin Department of Transportation: to screen and assess people in order to make a referral that fits the individual’s level of need in preventing future alcohol or drug-related driving incidences. Once again, thank you for taking the time to respond to the questionnaire. Please do no hesitate to contact me if you have any questions or concerns. (715) 395-1304. Best Regards, Dave Longsdorf, MA/IDP-AT Intoxicated Driver Program Coordinator Douglas County Department of Health and Human Services