SATOP Screening / Assessment 1. Client History / SATOP Screening Questions Question Title * 1. Name: First Name: Last Name: Question Title * 2. Address: Question Title * 3. Email Address: Question Title * 4. Phone Number: Question Title * 5. Date of Birth MM/DD/YYY Date Question Title * 6. Social Security Number Question Title * 7. Driver's License Number Question Title * 8. State DL was issued Question Title * 9. Gender Male Female Question Title * 10. If you are female, are you pregnant? Yes No Question Title * 11. Race/Ethnicity: How do you identify? (Check all that apply) Asian or Asian American Black or African American Hispanic or Latino/a/x Middle Eastern or North African Native American or Alaska Native Native Hawaiian or other Pacific Islander White Another race or ethnicity, please describe below Question Title * 12. Marital Status: Married Widowed Divorced Separated Never married Question Title * 13. How many children live with you? Question Title * 14. If children don't live with you, who do they live with? Question Title * 15. Do you have other people in your house that you care for? Yes No If yes, who? (please specify) Question Title * 16. Employment Status: Full Time Part Time Retired Disability Other (please specify) Question Title * 17. Employer Name Question Title * 18. What is your profession? Question Title * 19. Are you in the military? If so what branch and how long have you served? Yes No If yes, (please specify) Question Title * 20. Have you been discharged from the Military? Yes No Question Title * 21. What is your annual income? Question Title * 22. Do you have a reading problem? Yes No Question Title * 23. Do you have a hearing problem? Yes No Question Title * 24. Last School you attended Question Title * 25. Education (total number of years of schooling) starting with kindergarten? Question Title * 26. Graduated: Yes No Question Title * 27. Do you usually drink: Everyday Several times a week Mostly weekends Special occasions Never None of the above (please describe) Question Title * 28. Prior to arrest: How many times did you drink on average / week / month / year: How many drinks do you average / episode of drinking: Question Title * 29. After arrest: How many times did you drink on average / week / month / year: How many drinks do you average / episode of drinking: Question Title * 30. What kind of alcohol do you usually drink? Question Title * 31. Have you attended an alcohol education class or treatment before? Yes No If yes,When, where and why? Question Title * 32. Have you ever gone to anyone for help about your drinking or drug usage: Yes No If yes, What Age, where, when and why? Question Title * 33. What County/State was your most recent arrest? Question Title * 34. Date of arrest Question Title * 35. What was your BAC? Question Title * 36. What did you get charged with? Question Title * 37. How many people were in the car including you? Question Title * 38. Was there an accident? If yes, was there any injuries? Yes No If yes, (was there injuries)? Question Title * 39. What was your Attorneys Name? Question Title * 40. Attorneys Phone Question Title * 41. Next Court Date Question Title * 42. Which court or Judge was your most recent offense heard by? Question Title * 43. Referred By? Administrative Revocation, Abuse & Lose, Attorney, Court, MIP, Zero Tolerance Administrative Revocation Abuse & Lose Attorney Court MIP Zero Tolerance Other (please specify) Question Title * 44. Have you been ordered to attend the Victim Impact Panel? Yes No Page1 / 10 10% of survey complete. Next