DOEP Registration Form

Atlas Counseling and Education LLC

6707 Brentwood Stair Rd Ste 218

Ft Worth TX 76112

Ph./ Txt: 214.952.7505

First name

Last name

Phone

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Month you will be attending the class. (Please choose one)

May

June

July

August

September

October

November

December

Driver’s License Number and State (N/A if you don't have it)

Social Security Number (N/A if you don't have it)

Probation /Parole/ Lawyer/ (N/A)

Cause Number ( N/A if you dont have it)

County of Conviction ( Not Country)

Collin

Dallas

Denton

Johnson

Tarrant

Parker

Other

What is your race?

Marital Status

Highest Level of Education

Employment

How many times has your license now or ever been?

Please list the dates and charges for any previous and current arrests:

If charged with DWI, what was the BAC? (N/A if not applicable)

What was your age when you began drug activities/ drinking alcohol ?

What is your drug of choice

Have you ever thought you might have a drug problem?

Where do you usually drugs?

Short answerHave you ever received help from…?

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