Sos 258 Form PDF Details

The SOS 258 form serves as a critical component in the evaluation process for individuals seeking to address issues related to alcohol and drug use, particularly when these issues intersect with driving privileges. This comprehensive Substance Use Evaluation form, divided into two main sections, first requires detailed input from the driver or applicant regarding their general information, driving and nondriving conviction history involving alcohol or controlled substances, and a declaration of accuracy and consent for evaluation dissemination. The latter section is to be filled out by a qualified evaluator, detailing the applicant's lifetime treatment history for alcohol or drug use disorders, including specifics on types of treatment programs, medication-assisted treatment, support group history, and diagnostic impressions based on DSM-IV criteria. Furthermore, the form assesses the applicant's lifetime abstinence history, solicits a prognosis regarding their substance use, and concludes with recommendations for a continuum of care to address the individual's needs effectively. This in-depth evaluation aims to furnish the Michigan Department of State with a nuanced understanding of the applicant's substance use and its implications on their driving capabilities, thereby facilitating informed decisions regarding driving privileges. Keeping copies of all submitted documents, including the SOS 258 form, is advised for record-keeping and future reference.

QuestionAnswer
Form NameSos 258 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmi sos form 258, form sos 258, michigan sos evalutaion form sos 258, sos 258 form

Form Preview Example

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

 

Name of Program,

 

(e.g., Detoxification, Residential/Inpatient,

Beginning and

Treatment Outcome

Therapist or Group Leader,

Intensive Outpatient, Outpatient [individual

Ending Dates

 

and/or group], Education, Driver Safety

and Location

 

 

 

Intervention Course)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Sponsor Yes or No?

(e.g., AA/NA or Women For Sobriety)

 

 

 

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

Sustained Full Remission

 

On Agonist Therapy

 

Sustained Recovery

Early Partial Remission

Sustained Partial Remission

 

In a Controlled Environment

 

None Applicable

 

SOS-258 (01-02-14)

Page 1 of 2

Testing Instruments: Attach the actual instrument used.

 

 

 

 

Testing Instruments Used

Score

 

Interpretation of results

Explain how the results of this test

(e.g., ASI, SASSI-3, MAST/DAST)

 

correlate with the DSM-IV diagnosis on Page 1

 

 

 

 

 

 

 

Test 1:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Test 2:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Drug Screen: Administer a

10-panel urinalysis drug screen (or refer client) and submit a current laboratory report that includes at least two urine

integrity variables. Please include the confirmation test for any positive screen results.

 

Comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you administered an ethyl-glucoronide alcohol test, what were the results?

 

Lifetime Abstinence History:

 

 

 

 

 

 

Period of Abstinence

 

Abstinence Period Abated by What?

 

Comments

 

(Any abuse of prescription medication or use of

 

(Beginning and Ending Dates)

 

 

 

alcohol, controlled substance, or NA beer)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Client Prognosis:

 

 

 

 

 

 

 

 

Please check one: Poor

Guarded

Fair

Good

Excellent

Provide supporting facts for this prognosis (consider the client’s current living and work environments, lifestyle, relapse history, use of addictive prescribed medications, and any other relevant factors that may affect the overall prognosis):

Date of last use of:Alcohol and/or NA Beer:Controlled Substances:(Include illicit and addictive prescription drugs)

Continuum of Care Recommendations:

Please check all that apply:

 

 

 

 

 

Professional Treatment

Educational

Community Support Group

Other

 

None

 

Course

(e.g., AA/NA, Women for

 

 

 

 

 

Sobriety, SMART Recovery)

 

 

 

Reasons for recommendation or if none, please state reasons:

Certification of Evaluator:

As of this date, I certify that I have reviewed Section 1 and completed Section 2 and that this Substance Use Evaluation is true to the best of my knowledge and belief based on information obtained from the client, the client’s known substance use disorder and mental health history, and a client examination. I understand that the decision to grant, suspend, or reinstate an individual’s driving privileges rests solely with the Department of State, which may consider other facts or conditions when making this decision.

Evaluator’s Name (printed or typed)

Qualifications/Degrees

Date

 

Evaluator’s Signature

 

Telephone Number

 

Program Name

Program License Number

 

Address

City

State

ZIP

SOS-258 (01-02-14)

Page 2 of 2

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Step # 1 in filling in form sos 258

2. The subsequent step would be to submit all of the following fields: andor group Education Driver Safety, Intervention Course, and Location, Beginning and Ending Dates, Medication assisted treatment eg, Period, Frequency, Type, eg AANA or Women For Sobriety, Diagnostic Impression DSMIV, Sustained Full Remission Sustained, On Agonist Therapy In a Controlled, SOS, Sponsor Yes or No, and Sustained Recovery None Applicable.

Ways to prepare form sos 258 step 2

3. The following step is related to Testing Instruments Attach the, Interpretation of results, Explain how the results of this, correlate with the DSMIV diagnosis, Drug Screen Administer a panel, Abstinence Period Abated by What, alcohol controlled substance or NA, Period of Abstinence Beginning and, and Comments - fill out every one of these fields.

Part number 3 for submitting form sos 258

Concerning Abstinence Period Abated by What and Comments, make sure you do everything correctly in this current part. These could be the key fields in the PDF.

4. The next paragraph arrives with these particular form blanks to consider: Client Prognosis Please check one, Alcohol andor NA Beer, Controlled SubstancesInclude, Date of last use of Continuum of, Educational Course, Reasons for recommendation or if, Community Support Group eg AANA, Other, None, Certification of Evaluator As of, QualificationsDegrees, Telephone Number, and Date.

Part number 4 in filling out form sos 258

5. This last step to finalize this document is essential. You must fill in the displayed blanks, and this includes Certification of Evaluator As of, Telephone Number, Program Name, Address, Program License Number, City, State, ZIP, SOS, and Page of, prior to submitting. Neglecting to accomplish that can produce an unfinished and probably nonvalid form!

form sos 258 writing process detailed (part 5)

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