Spanish Client Information and Remote Waiver -Bradshaw

Nombre legal completo / Legal full name

First Name/Primer NombreLast Name/Apellido

Direccion de Casa / Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Número de Teléfono / Phone Number

Area CodePhone Number

Alterno Número de Teléfono

Area CodePhone Number

Correo electrónico / Email

example@example.com

Sexo / Gender

Fecha de Nacimiento / Date of Birth

MonthDayYear

Número de Licencia / Driver's License Number

Es este tu primer dui / Is this your 1st DUI?

¿Cuántos DUI ha recibido en los últimos 10 años? / How many DUI's have you received in the last 10 years?

Referido Por / Referred By

¿Cómo te enteraste de nosotros? / How did you hear about us?

Nombre del Abogado / Attorney's Name

Fecha de Arresto / VIO Date

MonthDayYear

Fecha de Condena / Conviction Date

MonthDayYear

# de Caso/Expediente / Case/Docket #

Cargos / Charges

BAC / Concentración de alcohol en sangre

Idiomas Preferidos / Language Preferred

Otro

Elva OchoaPor favor, elija la fecha en la que desea inscribirse. Las inscripciones se llevan a cabo en persona los viernes a las 12:45 pm. DEBE PROGRAMAR SU CITA DE INSCRIPCIÓN PARA LA SEMANA SIGUIENTE A COMPLETAR ESTA SOLICITUD

Date

Privacy Policy for Remote Client Services

Safety Center will provide Remote Client Services (Telehealth) utilizing the Zoom Virtual Meeting Platform. Some personal information such as your name, email address, and computer IP address will be shared with Zoom. Additionally, some meetings may be recorded and uploaded to a cloud for documentation of session completion. To participate in Zoom meetings, you must read and agree to Zoom’s Privacy Policy.

Safety Center will continue to maintain confidentiality as stated in our Confidentiality Policy. Client’s will also be held to the Confidentiality Agreement signed upon enrollment.

Remote Client Services Release

I agree to participate in temporary Remote Client Services (Telehealth) at Safety Center. I understand that specific technology is required to participate, and I certify that I have access to the required technology. Additionally, I have read and understand the Zoom privacy policy. I understand that Remote Client Services are being offered on a temporary basis due to the Coronavirus (COVID-19) pandemic, and that once the threat is eliminated, client services will then be available at the DUI Program location only. To receive credit for the session, I understand that I must:

Attend the session in a private room, free of distractions.
Stay for the entire session.
Not be under the influence of alcohol or other drugs during the session.

I understand that fees for DUI Program services will apply during this time, and that Safety Center will provide me with alternate payment options and methods during the Remote Client Services time
period.

I have read and agree to Safety Center's and Zoom’s Privacy Policy.

Legal Full Name

First NameLast Name

Signature

Date

Please attach a copy of your Photo ID

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Please attach a copy of your Court, DMV, or APS Form

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