SOS-258 (01-02-14) Page 1 of 2
SUBSTANCE USE EVALUATION
(ALCOHOL AND DRUGS)
SECTION 1: GENERAL INFORMATION and HISTORY (to be completed by driver/applicant)
Please print or type. Attach additional pages where necessary. PLEASE KEEP COPIES OF ALL DOCUMENTS (INCLUDING THIS FORM) THAT YOU SUBMIT.
Name (First, Middle, Last)
Date of Birth Driver’s License Number
Street Address
Telephone Number 8 a.m. – 5 p.m.
City
State ZIP
Lifetime Conviction History: List all driving convictions (e.g., operating while intoxicated or impaired driving) and nondriving convictions (e.g.,
drug crimes, domestic violence, MIP, or disorderly persons) involving alcohol or controlled substances. Include juvenile dispositions.
Driving
Convictions
Date
Bodily Alcohol Content or
Drug Type
(If known)
Nondriving
Convictions
Date
Bodily Alcohol Content or
Drug Type
(If known)
I authorize the Evaluator named on Page 2 to furnish the information set forth on this form and to discuss the information with the Michigan Department of State.
I understand this form may also be used as my written request for hearing. I certify that my responses contained in this document are true and accurate to the
best of my knowledge and belief.
Driver/Applicant’s Signature___________________________________________________________Date______________
SECTION 2: HISTORY and EVALUATION (to be completed by evaluator)
Please print or type. Attach additional pages where necessary.
Lifetime Treatment History for Alcohol and/or Drug Use Disorders: Attach each treatment plan and discharge report.
Program Type
(e.g., Detoxification, Residential/Inpatient,
Intensive Outpatient, Outpatient [individual
and/or group], Education, Driver Safety
Intervention Course)
Beginning and
Ending Dates
Name of Program,
Therapist or Group Leader,
and Location
Treatment Outcome
Medication assisted treatment (e.g., Methadone, Antabuse, Buprenorphine, or Campral): Medication: _____________________________
Prescribing Physician: ______________________________ Date started: _______________ Date ended:______________
Lifetime Support Group History: List all time periods of attendance and frequency.
Period Frequency
Type
(e.g., AA/NA or Women For Sobriety)
Sponsor Yes or No?
Diagnostic Impression (DSM-IV): Indicate all past and present alcohol, drug and mental health diagnoses.
Diagnoses:
Supporting facts for diagnostic impression:
Course specifiers (check all that apply):
Early Full Remission
Early Partial Remission
Sustained Full Remission
Sustained Partial Remission
On Agonist Therapy
In a Controlled Environment
Sustained Recovery
None Applicable
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