Referral Form To refer a participant, please fill out the following information and submit the form. Monitoring Authority Information Probation Officer (PO) * First Name Last Name PO Email * PO Phone (###) ### #### Court Judge First Name Last Name Court Paid * Yes No Promo Code Participant Information Participant Name * First Name Last Name Participant Phone * (###) ### #### Participant Email DOB * MM DD YYYY Age Group * Adult Juvenile If Juvenile please fill out the following Legal Guardian Information below Legal Guardian Name First Name Last Name Legal Guardian Phone (###) ### #### Legal Guardian Email Offense Referral Type Course Requirement Course Assessment Substance Abuse Assessment Complete Course/Assessment By * MM DD YYYY Course(s) * Handling Anger: Level 1 Handling Anger: Level 2 Cognitive Restructuring Impulsive Behavior Shoplifting/Theft Prevention Skills for Life: Critical Thinking Skills for Life: Self-Awareness Recovery Maintenance MIP/Minor Addiction Awareness No Course Suggestion Thank you for your referral! Our team will reach out to the participant directly to discuss enrollment options. The monitoring authority will be notified when the participant has completed enrollment.
