Intoxicated Driver Program (IDP) Assessment
Intake Form and Questionnaire

* Denotes a required field.

Client Information

Do you live in Eau Claire county? *

Yes

No

UNFORTUNATELY, YOU DO NOT QUALIFY

Only Eau Claire County residents may register on this website, as the state of Wisconsin requires IDP assessments to be done in the county in which you live.

Driver License Number*

First Name *

Middle Initial *

Last Name *

Previous Name(s)

Birth Date * Month January February March April May June July August September October November December

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024

Gender * Male Female

Address *

City *

State * WI

Zip *

Phone Number *

Email Address *

Phone Type *

Home

Work

Cell

May we text you?  Yes  No Cell Carrier * Select Provider AT&T Boost Mobile Cricket Metro PCS Nextel Powertel Sprint PCS Straight Talk SunCom T-Mobile TracFone US Cellular Verizon Wireless Virgin Mobile Other

Please note that the actual scheduling of your appointment will ONLY be done by phone.

Insurance/Income Information

At your assessment, a Driver Safety Plan (DSP) will be established. This DSP will, in most cases, require you to attend education classes or outpatient treatment (individual or group counseling). If you have health insurance, please check with your insurance company to see whether your plan covers AODA outpatient services at any area providers. It is also very helpful if you know what your deductible is and how much of it remains for the year. If you cannot provide this information on this application, please call your insurance company, obtain the information, and bring it along to your assessment appointment. This information will allow your assessor to establish your DSP on the day you are seen, rather than waiting for coverage information.

 

Is your annual household combined income less than $25,000?

Yes

No

We ask for this information because ECP may be able to assist you with finding funding sources for certain DSP programs.

I am asking for an appointment at Eau Claire Community Program for an IDP assessment.

I have been apprised of the following requirements and agree to comply with them:

1. The fee for this assessment is $300. This fee must be paid with Visa, MasterCard, or Discover. If I request a refund, I will receive the fee minus a $25 handling fee. This assessment is considered an evaluation only, not part of my treatment.
2. If I fail to appear for my assessment or give 24 hour notice to reschedule, I will be required to pay an additional $150 fee prior to rescheduling my appointment.
3. Failure to appear for an assessment, comply with a Driver Safety Plan, and/or pay the fees associated with the Driver Safety Plan may result in a report of non-compliance to the Wisconsin State Department of Transportation and indefinite suspension of my driver's license.
4. If after completion of my initial assessment, I need to amend/extend my Driver Safety Plan or be placed back into compliance after being in non-compliance, I will be charged a $100 fee.

 I have read, understand, and agree to the above requirements.

Type Your Full Name (This will act as your digital signature.)

Date

Payment Information

I agree to pay the $300 fee with the following credit card to complete my assessment application online.

Credit Card Type * Discover MasterCard Visa

Expiration Date * Month January February March April May June July August September October November December Year 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034

Credit Card Number *

Visa, Discover, MasterCard The verification number is a 3-digit number printed on the back of your card. It appears after and to the right of your card number. [x] Close box Security Code * (What's This?)

Please enter your billing address if it is different from your home address.

Address	City
State	Zip

Comments

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