North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services
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1 North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services 3008 Mail Service Center Raleigh, North Carolina Michael F. Easley, Governor Carmen Hooker Odom, Secretary Tel Fax Courier Michael Moseley, Director January 9, 2017 To Whom It May Concern: If you have been convicted in the State of North Carolina of Driving While Impaired (DWI) or driving while less than 21 years old after consuming alcohol or other drugs, and you live outside of North Carolina, please review the following information. In accordance with NC General Statute 122C-142.1, a substance abuse assessment is mandatory and an intervention such as substance abuse education or treatment must be completed before you can get your driver s license back. If you have completed a substance abuse assessment outside of North Carolina: You must have the out-of-state substance abuse assessment reviewed and approved by an authorized North Carolina DWI provider. You must complete the recommended intervention either in your home state or in North Carolina by an authorized NC DWI provider. If you have completed substance abuse education or substance abuse treatment outside of North Carolina: You must have the substance abuse education curriculum or documentation of your treatment reviewed and approved by an authorized North Carolina DWI provider. The provider will help you process this information, fill out a Certificate of Completion (508-R form) and send it in to the appropriate agencies for review to remove the stop on your driver s license. You will receive a copy of the Certificate of Completion for your records. Please contact an authorized North Carolina DWI Service Provider from the list provided. You may also refer to the NC DWI Services web site at to find out more about DWI Services in North Carolina. Respectfully, D. Jason Reynolds DWI Services Program Consultant Justice Systems Innovations Team An Equal Opportunity / Affirmative Action Employer
2 Life Changes DWI Centers P. O. Box 531 Danville, Virginia Fax: North Carolina DWI: Guidelines for out of state Offenders If you ve been charged with DWI in North Carolina, you must work with an agency that s approved and licensed by North Carolina. Life Changes is an approved agency and can help you fulfill North Carolina s legal requirements. 1. Our fee is $ and is payable by a cashier s check or money order and sent to the above address. Payable to Life Changes, Inc., in the amount of $ We are required by law to have copies of the following information in our file: (1.) your ticket, (2.) Breathalyzer results (3.) Arrest date (4.) NC Driving record. You may obtain this information from your attorney or the clerk of court in the county where you were charged with DWI. If this offense has been over 5 years, the court may not have the Breathalyzer results and you will not be required to provide the results. (6.) Send us a copy of your complete driving record in the state in which you are currently licensed (even if it is not current) and the intake sheet enclosed. 3. You must then obtain an assessment from a certified substance abuse counselor or agency that provides DWI/DUI services in your state. You will need to sign a release with the agency you are working with so we can communicate with them. You will need the agency to send us a letter on their letterhead with the assessment results. If you have already completed the appropriate treatment in order to satisfy North Carolina s legal requirements, we will use that treatment. The agency will need to state what you have completed the dates you began and the completion date. You will have to complete a DWI/DUI program to satisfy the state of NC, no online programs are accepted. 4. When we send the required 508 form to the North Carolina DMV, we will need for you get driving record also from NC DMV. If you had a previous NC drivers license, you may print off a non-certified record for us from DMV online services ( it has to be from NC DMV only). If you never had a NC driver license, you may call NC DMV at to obtain the customer number and fill out the attached form to send to NC DMV. 5. North Carolina will require you to pay a reinstatement fee and any other fees or fines that were never paid. You should call the DMV at and talk with an operator to find out how to pay that fee. 6. After we send in the 508 form, it will take up to 5 business days for the form to be processed by North Carolina DWI Services and then they will send it to DMV after it is approved. You can call the DMV at to check the status of your driver s license. It takes 1-3 days to clear the national registry, no letter is needed since this is done electronically. I hope that this information is helpful and will help you to fulfill your obligation to North Carolina. If you have any other questions, you may want to go to the DWI website that explains this information. The site is Gene P. Smith, CCAS, CCS Executive Director
3 Life Changes Intake Sheet Date / / Fax # and/or Name SS# Address City State Zip Home phone Work phone Birth date: / / 8. Gender: 9. Race (all that apply): 10. Ethnicity (choose 1): 11. Language Preference: 12. Marital Status (choose 01 Male 01 American Indian/ Alaska Native 01 Hispanic Puerto Rican 01 English 01 Never married 02 Female 02 Asian 02 Hispanic Mexican American 02 Spanish 02 Now Married 03 Black or African American 03 Hispanic Cuban 03 OTHER 03 Divorced 04 Native Hawaiian or other Pacific Islander 04 Hispanic Other 04 Separated 05 White 05 Unreported 05 Widowed 06 Unreported 06 Not Hispanic or Latino 13. Education Completed (choose 1): 14. Employment Status: 15. Health Insurance: 01 Less than 6 th grade 01 Full time (working 35 hours or more per week) 01 Private Insurance 05 NC Health Choice for Children 02 Less than 9 th grade 02 Part time (Working < 35 hours per week) 02 Blue Cross 06 Health Maintenance Organization (HMO) 03 Less than 12 th grade 03 Unemployed (Looking for work during past 30 days) 03 Medicare 07 other (e.g. TRICARE, CHAMPUS) 04 Completed HS/GED 04 Not in the labor force 04 Medicaid 08 None 05 Some college 06 Bachelor 07 Graduate Degree or higher 16. Arrest County: Breath or Blood Test LEGAL HISTORY Prior convictions & dates Pending charges Previous DWI s Court date County of Offense: BAC:
4 Checklist Your ticket & Breathalyzer (Blood) results. It can be gotten from clerk of court from the county of the offense or any documentation from the court on this including if they no long have it. Driving record from NC DMV. You will need to contact NC DMV and get your customer number and send off the attached form for a non-certified complete driving record, You will need to mark that on the form, the middle choice. $ Money order, intake sheet and any releases to Life Changes Current complete driving record from the state you are current licensed. Complete a DWI/DUI program in the state you are living. You have to complete a program (no exceptions). Online programs are not accepted. You have to be assessed according to their guidelines and treatment dates. We will accept this on the facility letterhead and sent or faxed to us directly. Pay the NC DMV reinstatement fee and any other fees you might owe in the state.
5 Life Changes Discharge Summary Client's Name: Beginning Date: / / Discharge Date: / / Cost: Case Coordinator: (Has/Has Not) Completed all AA meetings and outside requirements? Client's Participation was: Verbal with personalization Limited Verbal with self-exclusion Non-active Factors limiting client's participation: Education Physical Other (Please specify) None Emotional How would you describe client's attitude: Initially? Confused Refusal to accept limitations Unwilling to be there Unsatisfactory Satisfactory Finally? Positive Somewhat motivated; cooperative Barely complying Negative (Non-complaint) Satisfactory Has the client indicated changes in his/her drinking patterns since first starting in the group? Do you believe client understood and absorbed the basic information taught? Yes No Only partially Overall progress evaluation at end of treatment: Very good Good Poor Fair None Services Summary: Reason for discharge: Follow-up plan/recommendations/referrals: Counselor / / Date
6 NORTH CAROLINA DIVISION OF MOTOR VEHICLES DRIVER LICENSE SECTION Driver Privacy Protection Act Authorization To Disclose Personal Information Form DL-DPPA-2 I understand that personal information contained in my Motor Vehicle Record is protected by the federal Driver Privacy Protection Act and N.C. General Statue I hereby authorize the release of my personal information to the person named below. Print your full name as it appears on your driver license Your signature (MUST BE SIGNED) Your N.C. driver license number, SSN or ITIN & date of birth Date signed Person to receive information: Mailing address: Fees: Certified Complete History - $14.00 Uncertified Complete History -$10.00 Uncertified Limited History - $10.00 Circle one of the above to indicate the type of MVR to be released. Make checks payable to NCDMV. Mail this form and fees to: NCDMV, Driver License Records, 3113 Mail Service Center, Raleigh, NC 27699, please allow 10 business days processing time, this does not include US Postal service delivery time to or from the DMV. Form DL-DPPA-2, Revised January 2016 Previous editions are obsolete, DO NOT USE Life Changes Counseling P.O. Box 531, Danville, VA 24543
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