Drug and Alcohol Intensive Outpatient Program & Individual Substance Use/Addictions Counseling Sign Up
Full Name
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First Name
Last Name
Date Of Birth (DOB)
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Month
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Day
Year
Date
Sex
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Please Select
Male
Female
Other
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Format: (000) 000-0000.
E-mail
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example@example.com
Class Selection
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Please Select
IOP Program
Individual Counseling for Substance Use
Individual Counseling for Addictions
IOP & Individual Counseling
Are you looking to do virtual or in person?
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Virtual
In Person
Both
I'm not sure - I would like more information on both
Reason For Registering
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Please Select
Court Ordered
Education/Personal Reason
Court Case Number - If this does not apply to you, please put "N/A".
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Court Name or Probation Department - If this does not apply to you please put "N/A".
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How did you find out about us?
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Social Media
Word of Mouth
Court Referral
Internet Search
Other
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.
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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.
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Morning 6:00 AM – 12:00 PM
Afternoon 12:00 PM – 5:00 PM
Evening 5:00 PM – 9:00 PM
Please include any other information you would like for us to know:
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