West Texas Community Supervision
and Corrections Department

DWI TREATMENT COURT PROGRAM

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Your Information

Phase

Date

Name *

Cause # *

Home address

Apt #

City

State

Zip

Phone #

Sober days

Email address

Alcohol Monitoring Device

Device (circle one)

Mobile device Interlock device

Vendor

Last recalibration

Employment

Employed?

Yes No

Employer name

Phone number

Address

City

State

Zip

School

In school?

Yes No

School name

Address

Phone

GED?

Yes No

High school diploma?

Yes No

Amount of Fee Paid

Court cost

$

Receipt #

Date

Probation fees

$

Receipt #

Date

DWI program fee

$

Receipt #

Date

Restitution

$

Receipt #

Date

Service & Driving

Community service hours completed since last visit

Driving?

Yes No

If no, how do you get around?

License type (circle one)

TX DL Occupational

D.L. Number (TX-)

Recent traffic citation?

Next court date

Next Appointments

Aliviane/counselor

Date

Time

MRT class/STEP #

Date

Time

Family counseling/counselor

Date

Time

Life Skills services/counselor

Date

Time

Peer support services/coach

Date

Time

EHN/caseworker/Doctor

Date

Time

Medical appointment

Date

Time

Classes Completed

MADD/VIP ROP DWI DOE Anger Management Family Violence

MADD/VIP date (if completed)

Other class

Comments

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West Texas Community Supervisionand Corrections Department

DWI TREATMENT COURT PROGRAM

West Texas Community Supervision
and Corrections Department