New York State Office of Impaired Driver Clinical Assessment Form 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the Program/Practice Name and Provider Number at the top of the form. This information is essential for identifying the assessment context.
3. In the 'Motorist Last Name' and 'First Name' fields, enter the individual's name along with their DMV Client ID#. Ensure accuracy as this links to their driving record.
4. Proceed to the 'Impaired Driver Assessment' section. For each subsection (a-h), provide detailed findings and conclusions based on your evaluation. Use bullet points for clarity if needed.
5. For sections like Substance Use History and Mental Health, be thorough in documenting all relevant details, including past treatments and current medications.
6. Complete the Diagnosis and Determination section by indicating primary, secondary, tertiary, and quaternary diagnoses as per DSM guidelines.
7. Finally, ensure that you sign and date the form at the bottom before saving or sharing it directly from our platform.

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