Get Started with Your DUI Program Today

Pre-Enrollment Form

Join California Recovery Center’s state-licensed DUI programs and begin your path toward responsibility, renewal, and lasting positive change.

Send us a message

If you need any help, kindly contact us and provide the following information.

Your Name(Required)

First Name Last Name

Phone(Required)

Email(Required)

Birthdate(Required)

Your Address(Required)

Street Address Address Line 2 City ZIP Code

More Information

Driver's License Number(Required)

Referral Source

Court Case / Docket #

Mandated Program Length

Conviction Date

Violation Date(Required)

Blood Alcohol Content Level

BAC Level

Upload your Photo ID(Required)

Max. file size: 50 MB.

Court, DMV, or APS form(Required)

Max. file size: 50 MB.

Before You Submit

By submitting this form, you acknowledge and agree to the following: All information provided is true and accurate to the best of your knowledge. Submission of this form does not guarantee enrollment until reviewed and confirmed by California Recovery Center staff. You understand that your personal information will be used solely for program enrollment and communication purposes in accordance with HIPAA and applicable privacy laws. False or misleading information may delay or affect your program placement. CRC DUI staff will contact you to schedule and finalize your enrollment. You may also call our DUI contact number at (916) 587 8384.

I have read and agree to the terms above.