Telehealth form

Online Drug/Alcohol Evaluation

This service is ONLY available to those people that are looking to resolve an issue in GA or FL OR have residence in GA or FL.
This form and payment will be the first step to requesting an online telehealth evaluation appointment.
Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's E-mail*
example@example.com
Mobile Number*
Please list your probation office and officer's last name here. (Example- Lowndes County Probation, Officer Smith.) If you are on probation outside of Lowndes County GA, please provide your officer's contact information as well. If you are not on probation, please provide the information for the person that has referred you to this evaluation.*
Which method of contact do you prefer? (phone or email?)*
Upload your probation sentencing sheet (a picture is fine, as long as it is readable,) as well as a picture of your ID. IF YOU ARE NOT ON PROBATION, then please upload your criminal history and ID (you do not have to upload this if you are completing a probation requirement.)*

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My Products*

Online Alcohol/Drug Assessment

This appointment satisfies area court system requirements for a detailed drug/alcohol assessment, as well as a Clinical Evaluation as required by DDS for some drivers.

$200.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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Online Drug/Alcohol Evaluation