Clinical Evaluation Contract
Anyone who receives a DUI in Georgia is required to attend DUI School, have a clinical evaluation from a State approved Clinical Evaluator, and complete any treatment recommendation with a State approved Treatment Provider. These requirements, effective 7/1/1997 and 7/2008 are State law. The State approved evaluators and treatment providers can be found on the web at Other conditions may be required for license reinstatement fees. Call the Department of Driver's Services at 678-413-8400 for more information on your case.

Thank you for choosing me to conduct your clinical valuation. By agreeing and doing your electronic signature below, you agree to the following:
* The client will select a clinical evaluator from the State Registry and have the DUI School forward the NEEDS assessment to that evaluator.
* The client will select any evaluator they wish from the Registry.
* The client is entitled to a second opinion.
* The client will select a treatment provider from the State Registry. If this is not done within 60 days of the evaluation, the evaluator may conduct another evaluation.
* The client will pay the clinical evaluation fee of a minimum of $110 in full at the time of service.
* The Clinical Evaluator (CE) attests that they are currently on the State Registry of approved Clinical Evaluators.
* The CE will determine the level of treatment recommended not the place or length of treatment.
* The Treatment Provider determines the number of groups.
* The CE will show the client the list of State approved treatment providers on the Registry.
* The CE will forward the necessary forms and information to the selected treatment provider after the client signs the necessary release of information form.

By clicking and e-signing below, I agree that I have read and understood the terms of this agreement and received a copy of this contract.
Sign in to Google to save your progress. Learn more
Please acknowledge below: *
Please type your full name below: *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Atlanta Intervention Network.