Class/Program Sign Up

Drug and Alcohol Intensive Outpatient Program & Individual Substance Use/Addictions Counseling Sign Up
Full Name*

First NameLast Name
Date Of Birth (DOB)*

MonthDayYear
Date
Sex*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Class Selection*
Are you looking to do virtual or in person?*

VirtualIn PersonBothI'm not sure - I would like more information on both
Reason For Registering*
Court Case Number - If this does not apply to you, please put "N/A".*
Court Name or Probation Department - If this does not apply to you please put "N/A".*
How did you find out about us?*
Which days work best for you? Please note that selecting a preferred day does not guarantee availability; we will do our best to accommodate your schedule. You may select multiple days if more than one applies.*

MondayTuesdayWednesdayThursdayFridaySaturday
Which times work best for you? Please note that selecting a preferred time does not guarantee availability. We will do our best to accommodate your schedule. You may select multiple times if applicable.*

Morning 6:00 AM – 12:00 PMAfternoon 12:00 PM – 5:00 PMEvening 5:00 PM – 9:00 PM
Please include any other information you would like for us to know:
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Drug and Alcohol Intensive Outpatient Program & Individual Substance Use/Addictions Counseling Sign Up