Virtual Online Service Request
1.
What is your complete name? Su nombre completo?
2.
What is your case number? su numero de caso?
3.
What is your main phone number? su numero telefonico principal?
4.
What is your email address? su correo electronico?
5.
Would you rather receive any pending appointments or class/course assignments via online/virtual with video or live in a office/classroom setting? prefiere recibir clases/citas por via electronica/virtual usando video o desea recibir servicios en vivo en una aula/oficina?
Services via online/virtual with video. Servicios electronico/virtual con video
Services live in an office/classroom setting. Servicios en vivo.
6.
Do you have access to a desktop/laptop computer, tablet/iPad or Smartphone? Tiene acceso a una computadora, dispositivo o telefono inteligente?
Yes/ Si
No
7.
If you have a laptop/desktop computer, do you have webcam and mic capabilities? Si tiene acceso a una computadora, tiene capacidad de video e microfono?
Yes/ Si
No
Not Applicable
8.
Do you have access to internet connection or hotspot? Tiene acceso a coneccion de internet?
Yes/ Si
No
9.
What type of class or appointment are you trying to schedule? Que tipo de cita o horario de clase esta programando?
DUI Class assignment/ Clase de DUI
DUI Evaluation appointment/ Evaluacion de DUI
Educational class session such as Anger Management, Parenting, Values (Anti-Theft) or Driving While License Suspended course/ Curso educativo, por ejemplo- Control de Ira, Valores, Manejando con la Licensia Suspendida o curso de Padres
Treatment Program assessment or group session/ Evaluacion o session en grupo de Tratamiento
Domestic Violence assessment/ Evaluacion de Violencia Domestica
Victim Impact Panel/ Panel de Victimas
Other/ Otro
10.
If you opt to online/virtual services with video do you agree to engage in services in a private and confidential space during session? Si escoge recibir servicios electronico/virtual esta de acuerdo en estar ubicado en un entorno privado y confidencial durante la sesion?
Yes/ Si
No
11.
In order to opt in online/virtual services with video, you will be required to download the Zoom app in order to engage in services. Do you agree to download such app? Para recibir servicios electronico/virtual estara requerido bajar la aplicacion de Zoom a su computadora o dispositivo. Esta de acuerdo o tiene acceso bajar tal aplicacion?
Yes/ Si
No
Current Progress,
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