DUI/DWI Enrollment Form
Identifying Information Form (​Health Insurance NOT Accepted​)

Therapist​: Dr. George L. Wheeler Sr​

Cost of Evaluation $250.00 is due upon evaluation.
Cost of Emergency Evaluation/need within 24 hours $350.00.

Email address *
Client Last, First MI *
Your answer
DOB *
MM
/
DD
/
YYYY
Sex
Race
Phone number *
Your answer
Occupation
Your answer
Number of violations *
Your answer
State or States violations occurred *
Your answer
Probation Officer (Case Mgr) Name *
Your answer
Probation Officer (Case Mgr) Number *
Your answer
Probation Officer (Case Mgr) Fax Number *
Your answer
Lawyer/Atty Name *
Your answer
Lawyer/Atty Office Number *
Your answer
Lawyer/Atty Fax Number *
Your answer
Lawyer/Atty Email *
Your answer
The above information is correct and I have/have not given Dr. Wheeler a copy of all of the documentation pertaining to my violations given to client by the courts in order to properly evaluate the above client.​ *
Required
A copy of your responses will be emailed to the address you provided.
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