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DUI Enrollment Assessment Forms
We're happy you are here!
Welcome to Step 1: Assessment Forms
Once these forms have been submitted, please return to duiprogramsky.org for instructions to schedule your in-person assessment, which can be found under STEP 2.
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* Indicates required question
I understand these forms must be completed before I request an appointment for assessment under Step 2.
*
I understand.
Who is completing this form?
*
Client (I am the person ordered to take classes.)
Friend of client
Family member of client
Other:
Which location are you wanting to attend classes?
*
Choose
Lexington
Richmond
Winchester
First Name
*
Your answer
Last Name
*
Your answer
Middle Initial
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Your answer
County
*
Your answer
Zip Code
*
Your answer
Phone Number
*
Your answer
Email address
Your answer
Emergency Contact
Name, number, relationship to you
Your answer
Gender
*
Male
Female
Marital Status
*
Unknown
Divorced
Married
Separated
Single
Race
Unknown
African American
American Indian
Alaska Native
Hispanic
White
Other
Clear selection
Household Income
0-9,999
10,000-19,999
20,000-29,999
30,000-39,999
40,000-49,999
50,000-59,999
60,000-69,999
70,000-79,999
80,000-89,999
90,000-99,999
100,000+
Clear selection
Maiden Name/Other Name
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
SS# (enter all 0s if you do not have one)
*
Your answer
If no SS#, please check one
Unknown
No U.S. SSN
Driver's License Number
Your answer
Current License Status
*
Suspended License
No U.S. License
Ignition Interlock Restricted License
Active Unrestricted License
Other:
Required
Number of DUI convictions in 5 years (including this one)
*
Your answer
Number of Lifetime DUI convictions, including this DUI
*
Your answer
Court Case #
Your answer
Court Case Forms
This information is required for assessment.
Please contact your court of conviction to get a copy of your
AOC494
(Notice to Attend classes) and a copy of your
Citation
.
You will need these forms for your assessment.
*These forms are required for DUI convictions in KY only. Other forms apply for other states.
*
I have a copy of my Citation and AOC494 and will bring them to my assessment.
I will contact the court and bring a copy of my Citation and AOC494 with me to assessment.
This DUI was received in another state.
Other:
Required
Citation # (not required)
Your answer
Violation Date
This must match the court and state records.
This is the date listed on the citation of when you were charged with this DUI.
MM
/
DD
/
YYYY
Conviction Date
This must match the court and state records.
This is the date you pled guilty to this DUI.
Your answer
Conviction State
*
Your answer
Conviction County
*
Your answer
Did your DUI involve alcohol?
*
Choose
Yes
No
Was alcohol measured?
*
Choose
Yes
No
Reason not Measured
Not Requested
Refused
If tested, Method used
Breath
Blood
Urine
Other:
Clear selection
BAC
(Blood alcohol content at time of DUI)
Your answer
Did you DUI involve drugs?
*
Choose
Yes
No
Drugs involved. Check all that apply
Amphetamines
Inhalants
Cocaine
Marijuana
PCP
Hallucinogens
Opiates
Sedatives
Were drugs tested?
*
Choose
Yes
No
Reason not tested
Not requested
Refused
If tested, Method used
Blood
Urine
Other:
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