1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Repeat DUII Prevention Plan

Name:    Date of Birth:

List the three circumstances where you were most likely to drink in the past:

List three important strategies for preventing a future incident of driving after the use of intoxicants:

What do you know now that if you had known prior to the DUII may have prevented you from receiving it in the first place?

What are your three most motivating factors for not receiving an additional DUII?

This document is being signed by: ClientPersonal Representative, see below

If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.

Full legal name of Personal Representative:

Relationship to client:

Definition of Personal Representative:
For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.
For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.