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 two business days 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 [email protected]

First Name *

Middle Initial

Last Name *

Cell Phone *

Email *

Address *

Apt. #

City *

State *

Zip Code *

Drivers License # *

DL State *

Expiration Date *

Preferred Method of Contact *

Birthdate *

Last 4 of Social *

Gender *

Marital Status *

Employment Status *

Race *

Education *

Please confirm the following information: ALL REQUIRED*

SECTION 2: LEGAL HISTORY

Total Arrests Lifetime?

Total DUIs Lifetime?

Total DUIs Past 10 Yrs?

Total DUIs Past 5 Yrs?

Total MJ Possession Arrests?

Total Other Drug Poss Arrests, not MJ?

SECTION 3: TREATMENT HISTORY

How Many Treatment Events* Have You Had Lifetime for Alcohol/Drugs

PLEASE NOTE THE NUMBER OF TREATMENT EVENTS YOU HAVE HAD LIFETIME IN EACH CATEGORY

AA/NA meeting

Detox Facility

Intensive Out-Patient

Counseling

In-Patient Rehab 15-60 days

In-Patient 61+ days

* A Treatment event is consecutive time period where you were being treated for substance abuse. If you went to AA meetings for 3 years, that is one event. 60 days in a rehab facility is one event.

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, Cobb County, City of Woodstock, Valdosta Police, Meriweather Sheriff's Dept., etc.)

What was the month and year of the event that created the need for this evaluation?

Month

Year

Has your case been fully ajudicated in court?

Yes No

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 or 100% virtually?

EXPIDITED SERVICE

* Normal processing time for State-Certified evaluations is 10 to 15 business days. If you have a need for a faster return, we offer expedited services for virtual evaluations (expedited services are not available for in-office administration). Keep in mind, the clock doesn't start ticking until you have completed your responsibilities in the process (i.e. completing online forms and signing required documents electronically (20 minutes), finishing online testing (35 minutes) and reasonable availability for the clinical interview via zoom (20 minutes)). We will work weekends and holidays to meet the expedited service level you have paid for, but we need your timely efforts to make it happen.

You will be given the opportunity to sign up for expedited services on the payment screen

Please Note: If you are registering for this evaluation due to receiving a DUI, you are also required to enroll and complete the 20-hour state DUI / Risk Reduction Course. LifeSwitch offers this course several times each month in both “live” classroom and “virtual” classroom settings.

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

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