Assessment/Treatment Report for DASA Certified Agencies

This report is used to determine whether drivers can regain their driving privileges after alcohol-related violations.

Instructions

The report must be completed and signed by a counselor from a state-certified facility.
Incomplete or illegible reports won’t be processed.

Client and agency information

The top area of the form must include information for both you and your client.

Assessment

Note: Don’t send an assessment if your client is on deferred prosecution for a DUI. You can determine this by reviewing the client’s current driving record.

Enter the date an assessment was conducted.
Mark only one of the boxes:
- Alcohol/drug information school is recommended. — Check this box if the client is diagnosed as having insufficient evidence of substance abuse/dependence.
- Treatment is required — If you check this box, you must also check either “substance abuse” or “substance dependence” based on your training, procedures, or policies.
- No treatment is required. — Check this box for clients who are in full remission, not patients who need Alcohol/Drug Information School (ADIS).

Information School

Check this box if the client has completed ADIS, and provide the date of completion.

Treatment Report

If you are reporting compliance or non-compliance, enter the date and check the appropriate box:

Compliant can mean the client is in compliance after beginning treatment, is back in compliance, transferred in, or has completed treatment.
Non-compliant can mean the client failed to obey rules, or was transferred out of the current program and required additional treatment.

Completing the form

When you have completed the form, print it on white paper, print and sign your name, and provide the date and place you signed it.