DWI Intervention Registration Form

This standardized program is 32 hours/16 sessions in length and is designed for multiple DWI offenders and/or others who have alcohol/drug-related problems for which the first offender program was not designed to address. The program's purpose is to intervene in the alcohol/drug-abusing lifestyles of the offenders in order to encourage entry into treatment where indicated as well as to prevent further substance abuse-related problems.

Class Rules and Expectations – Student Acknowledgment

As a participant in Atlas Counseling and Education LLC programs,

I understand that I am expected to follow all rules and guidelines outlined below.

These rules are in place to ensure a safe, respectful, and productive learning environment for all participants.

Attendance and Punctuality

I understand that late arrivals are not allowed.

I will plan ahead to ensure I am present, on time, and in a safe and appropriate location for class.

Class Environment and Conduct

I understand that I am in a virtual and/or in-person classroom and will respect the opinions of others at all times.

Disrespectful behavior, foul language, threats, or any actions perceived as harmful will result in immediate dismissal and may be reported to authorities.

I understand that I must remain stationary and attentive during class. I am not allowed to wander around or engage in distracting activities.

I understand that I may not attend class while driving, working, or engaged in personal errands such as shopping, cooking, yard work, bathing, or similar activities.

Technology and Participation

I understand that my camera must remain on and I must be visible at all times during class.

I am required to actively participate in discussions and respond appropriately when called upon.

I understand that watching TV, using social media, or engaging in side conversations during class is not permitted.

I understand that I am responsible for having a reliable internet connection. If I am disconnected and unable to return within 10 minutes, I will be marked absent and may be dropped from the class with no refund.

Privacy and Confidentiality

I understand that privacy is critical. I will attend class in a secure and private location and will use a personal headset when possible to protect confidentiality.

I understand that recording of any class session is strictly prohibited.

Substance Use and Behavior:

I understand that the use of drugs, alcohol, smoking, or dipping tobacco during class is strictly prohibited and will result in immediate dismissal.

Eating during class is highly discouraged.

Attendance Policy

I understand that most courses do not allow absences. The DWI Intervention Program allows a maximum of two absences.

Students are not to be driving, sitting in a moving car, or sitting or attending class in a public area.

No other individuals are allowed on camera or in the area where you are attending the class.

I understand that upon a second absence in the DWI Intervention Program, I will be dropped from the course. Any approved make-up sessions will require a $40 fee per absence.

I understand that non-excused absences include situations such as work conflicts, family matters, transportation issues, or similar personal responsibilities.

Assignments and Completion Requirements

I understand that I am responsible for completing all homework, assignments, and pre- and post-tests in a timely manner.

I understand that all required work must be submitted within 24 hours after course completion. Failure to do so may delay my certificate up to 10 days or longer.

I understand that I will not receive my certificate of completion until all program requirements and any required make-up sessions are completed.

Payment and Refund Policy:

I understand that payment is required to attend class.

I understand that all fees and make-up class costs are non-negotiable.

I understand that there are no refunds for any reason.

General Acknowledgment

I understand that these rules are not subject to debate and are designed to protect the program’s safety and integrity.

I understand that I was provided access to these rules at the time of registration, and it is my responsibility to read and follow them.

I understand that if a class is canceled, it will be rescheduled at the earliest available date.

In the DWII Program, all students are allowed two absences. On the third absence, the student will be withdrawn with no credit, and no refunds will be given.

Being completely withdrawn from the class is possible if the student refuses to comply with class expectations and rules, as deemed necessary by the admin. or instructor. The client will receive a written notice of removal.

Release of Information Statement

I hereby authorize Atlas Counseling & Education LLC to release and/or exchange information related to my participation in the DWI intervention Program with the person or agency designated by the court. This information may include verification of enrollment, attendance, progress, and program completion.

I understand that this authorization is voluntary and that I may revoke it at any time by providing written notice, except to the extent that action has already been taken based on this authorization. This authorization will remain in effect until the completion of the program unless revoked earlier.

I understand that this authorization does not permit the release of confidential clinical or therapeutic information without my specific written consent.

By signing below, I acknowledge that I have read and understand this authorization and give my consent for the release of information as described above.

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Financial Responsibility

I understand that I am responsible for all fees associated with my participation in this program/class. All payments are due as outlined at the time of registration and must be paid in full in order to receive credit or a certificate of completion. I acknowledge that failure to complete payment obligations may result in suspension or termination from the program.

In the event of a payment dispute, chargeback, or financial claim initiated through a bank, credit card company, or legal entity, I authorize Atlas Counseling & Education LLC to provide any necessary documentation to respond to and resolve the dispute. This may include, but is not limited to, proof of payment, class attendance records, written communication, and signed agreements acknowledging my enrollment and payment responsibility. I understand that this disclosure is limited solely to information required to verify the legitimacy of the transaction and does not constitute a release of confidential therapeutic or clinical information.

By participating in this program, I acknowledge and agree to these financial terms.