Virtual Online Service Request

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* 1. What is your complete name? Su nombre completo?

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* 2. What is your case number? su numero de caso?

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* 3. What is your main phone number? su numero telefonico principal?

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* 4. What is your email address? su correo electronico?

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* 5. Would you rather receive any pending appointments or class/course assignments via online/virtual with video or live in a office/classroom setting? prefiere recibir clases/citas por via electronica/virtual usando video o desea recibir servicios en vivo en una aula/oficina?

Services via online/virtual with video. Servicios electronico/virtual con video

Services live in an office/classroom setting. Servicios en vivo.

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* 6. Do you have access to a desktop/laptop computer, tablet/iPad or Smartphone? Tiene acceso a una computadora, dispositivo o telefono inteligente?

Yes/ Si

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* 7. If you have a laptop/desktop computer, do you have webcam and mic capabilities? Si tiene acceso a una computadora, tiene capacidad de video e microfono?

Yes/ Si

Not Applicable

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* 8. Do you have access to internet connection or hotspot? Tiene acceso a coneccion de internet?

Yes/ Si

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* 9. What type of class or appointment are you trying to schedule? Que tipo de cita o horario de clase esta programando?

DUI Class assignment/ Clase de DUI

DUI Evaluation appointment/ Evaluacion de DUI

Educational class session such as Anger Management, Parenting, Values (Anti-Theft) or Driving While License Suspended course/ Curso educativo, por ejemplo- Control de Ira, Valores, Manejando con la Licensia Suspendida o curso de Padres

Treatment Program assessment or group session/ Evaluacion o session en grupo de Tratamiento

Domestic Violence assessment/ Evaluacion de Violencia Domestica

Victim Impact Panel/ Panel de Victimas

Other/ Otro

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* 10. If you opt to online/virtual services with video do you agree to engage in services in a private and confidential space during session? Si escoge recibir servicios electronico/virtual esta de acuerdo en estar ubicado en un entorno privado y confidencial durante la sesion?

Yes/ Si

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* 11. In order to opt in online/virtual services with video, you will be required to download the Zoom app in order to engage in services. Do you agree to download such app? Para recibir servicios electronico/virtual estara requerido bajar la aplicacion de Zoom a su computadora o dispositivo. Esta de acuerdo o tiene acceso bajar tal aplicacion?

Yes/ Si