Preview DUI | Granite Wellness Centers

You will be contacted within 5 Business Days of completing this appointment. You will need to attend in person to complete your enrollment.

Location(Required)

You are scheduling an enrollment appointment at our Auburn location:

12183 Locksley Lane
Suites 100-104
Auburn, CA 95602

You are scheduling an enrollment appointment at our Grass Valley location:

180 Sierra College Drive
Grass Valley, CA 95945

You are scheduling an enrollment appointment at our Lincoln location:

1530 Third Street
Suite 106
Lincoln, CA 95648

You are scheduling an enrollment appointment at our Roseville location:

406 Sunrise Avenue
Suite 100
Roseville, California 95661

Legal Full Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Alternate Phone

Email(Required)

Gender(Required)

Male

Female

Birth Date(Required)

Driver's License Number(Required)

Is this your 1st DUI?(Required)

Yes

How many DUI's have you received in the last 10 years?(Required)

Referred By

How did you hear about us?(Required)

Postcard

Attorney

Court Referral

Internet Search

Word of Mouth

Social Media

Other

VIO Date(Required)

Conviction Date

Case/Docket #

Charges(Required)

23152

23103

23140

W/MEDS

W/DRUGS

BAC

Language Preferred(Required)

English

Spanish

Other

Other Language

Would you be interested in attending the DUI Class in a Live Virtual Remote Session?(Required)

Yes

DUI Virtual Services Eligibility Screening

This screening tool helps determine whether a client with a DUI (Driving Under the Influence) offense is eligible to participate in virtual services instead of in-person services.

Do you have reliable access to the internet?(Required)

Yes

Do you have a computer, tablet, or smartphone capable of running virtual meeting software?(Required)

Yes

Are you comfortable using video conferencing applications (e.g., Zoom, Microsoft Teams)?(Required)

Yes

Do you have a private, quiet location to participate in virtual sessions without distractions?(Required)

Yes

Do you agree to keep your camera on during virtual sessions?(Required)

Yes

Have you successfully participated in a virtual meeting (e.g., Zoom, Microsoft Teams) in the past?(Required)

Yes

Do you have access to headphones or a private space to ensure confidentiality during sessions?(Required)

Yes

Are you willing to do a test session to confirm your ability to access and use the virtual platform?(Required)

Yes

Can you commit to being on time and actively participating in all required virtual sessions?(Required)

Yes

Do you understand that missing sessions or failing to actively participate may result in a requirement to switch to in-person services?(Required)

Yes

Are you comfortable completing and submitting assignments online (e.g., worksheets, reflections, or self-assessments)?(Required)

Yes

Have you had any technical or engagement issues in previous virtual treatment programs (if applicable)?(Required)

Yes

Please explain previous technical or engagement issues(Required)

Are you currently in a stable enough condition to participate in group discussions without being under the influence?(Required)

Yes

Do you have a safety plan in place in case you experience cravings or distress while attending virtual sessions?(Required)

Yes