MRT Face Sheet

MRT Registration Form
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Driver's License #
State Issued
County where you live
Cell Phone Number
Cell phone Carrier Sprint, T-Mobile, etc
Have you been assigned a Probation Officer?

YES NO
Probation Officer Name
Probation Officer Email
example@example.com
Do you have an attorney/ public defender?

YES NO
Attorney Name
Attorney Email
example@example.com
If currently doing UA's (Drug Testing) for probation/pre-trial? What is your UA ID#?
Do you have any pending charges?

YES NO
Charge #1
County
Charge #2
County
Charge #3
County
Why are you signing up for MRT? Please describe in detail.
How did you hear about us?

Internet Search Google Ad Attorney Probation/ Pre-trial Doing UA's Other
For MRT, which class time do you prefer (ONLINE VIA ZOOM)?

Thurs@ 730PM (CLOSED) Fri@ 530PM
Today's fee will include the Intake ($75), Workbook ($30), and First Session ($30) = $135

You will need to get the MRT workbook from the office before group or we will need to mail it to you ($5).

10% Discount offered if balance PAID IN FULL at the time of the intake/ applies to class fee only. Class fee for 12 weeks is $360 or $324 with the discount.
Do you want to PAY PER CLASS or PAY IN FULL today?

PAY PER CLASS PAY IN FULL
An invoice and zoom link will be emailed to you within 24 hours. Make sure to check your junk mail.
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MRT Registration Form