Thank you for choosing LifeSwitch to administer your alcohol and drug evaluation. Once you submit this form you will be taken to the payment screen. Payment must be received to complete your registration. Within 24 hours you will receive instructions on how to access and electronically sign the State of Georgia's required documents. After completion we will be in touch within one business day to schedule your evaluation.

If at any time you need help with any part of this process please call us at 770-731-2479 or email Cindy, our administration manager at [email protected]

First Name *

Middle Initial

Last Name *

Cell Phone *

Email *

Address *

Apt. #

City *

State *

Zip Code *

Preferred Method of Contact *

Birthdate *

Last 4 of Social *

Drivers License # *

DL State *

Expiration Date *

Please confirm the following information: ALL REQUIRED*

Are you required to take this evauluation due to DUI?

Yes No

If Yes, who was the agency that arrested you (e.g., Fayette County, Coweta County, Fayetteville Police, Newnan Police, Peachtree City Police, etc.)

If Yes, how many DUI's have you had lifetime, including this one?

If Yes, how many DUI's have you had in the past 10 years, including this one?

If not for DUI, briefly describe the reason you are required to have this evaluation completed.

Will you be taking this evaluation in our office ($155) or 100% virtually ($195)? *

Have you been assigned a Probation Officer?

Yes No

Officer Name *

PO Phone *

Jurisdiction / Agency *

PO Email *

We will send your evaluation results to your probation officer with a copy to you. If you have an attorney and would like us to send the results to him / her as well, please list them below

Attorney Name

Attorney Phone

Attorney Email

24 Hour Rush Service (+ $75.00);

Any additional comments you think we should know, please add below

QUESTIONS?

GA DDS CERTIFIED DRIVING COURSES OFFERED IN LIVE OR VIRTUAL CLASSROOMS

Clinical Evaluation Signup

OFFICE HOURS:

(770) 731-2479