SA Eval Appointment Request

Appointment Request

Substance Abuse Evaluation
Complete this form to request a Substance Abuse Evaluation. After you submit, a therapist will respond to you via email within 48 hours to complete your scheduling.
Name *

First Name Last Name
Email *

Confirmation Email example@example.com
Location/ Language Preference *

Denton Lewisville Spanish Speaking
Referral Name and Agency: If you were referred by your probation officer or case worker, enter their information here (e.g. Jan Smith, Denton Adult Probation)
Referral Name
Referral Agency

Denton County Adult Probation None Other
Please provide any additional information you would like:
Should be Empty: