Court Services Enrollment Request
This form is required for all court-ordered services including Domestic Violence, Anger Management, Impulse Control, Assessments, Parenting, and Reunification. All required fields must be completed before scheduling.
Client Information Section
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
Confirmation Email
Confirm Email
Preferred Contact Method
*
Phone Call
Text Message
Email
Court Information Section
Type of Court-Ordered Service (Select all that apply)
*
Domestic Violence Classes
Anger Management Classes
Parenting Classes
Mental Health Evaluation/Assessment
Substance Use Evaluation/Assessment
Reunification Services
Substance Use Counseling
Impulse Control
Other
Number of classes or sessions if ordered by the court?
Please enter the number of sessions, weeks, or classes listed on your court order (example: 16 weeks, 26 classes, or 12 sessions)
Court Name
*
Please Select
Las Vegas Justice Court
North Las Vegas Court
Henderson Justice Court
Pahrump Justice Court
Clark County Family Court
Other
Case Number
Probation Officer (If Applicable)
Upload Court Referral/ Court-Order
*
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Upload Government-Issued Photo ID
*
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Submit
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