Attorney/Probation Officer And Client Referral Form

First name

Last name

Phone

Date

REFERRING AGENCY AND/OR PERSON(S):

Alcohol Education (4 hours) $100

Alcohol Education (8 hours) $145

Theft Awareness (4 hours) $50

Domestic Violence / Anger Management (4 hours) $100

Domestic Violence/Anger Management Follow-up Sessions

Outpatient Counseling / Intensive Outpatient Counseling (1 hour intake $75) (Individual Session $45)

Drivers License Evaluation $200

Substance Abuse Assessment $125

FORM OF PAYMENT: Venmo, Cashapp, Paypal, Zelle, Credit Card, Debit Card

III. DISCLOSURE INFORMATION (to be signed by the person being referred)

I, hereby authorize Schroeder Counseling, Inc. as indicated above, its Director or designee, to release, exchange and/or communicate information to (enter referring agency and/or persons) The extent and nature of this information will concern my attendance, progress, services received and recommendations for additional services when appropriate. The purpose of this disclosure is to assist this agency and/or persons arriving at an appropriate disposition in my case. In addition, I give authorization to Schroeder Counseling, Inc. to contact me at the address and/or phone provided above regarding the enrollment and attendance of the referral made. This authorization will remain in effect until the purpose for which it was given no longer exists. In the case of criminal justice referrals, the authorization will expire when the program receives official written notices of a change in my legal status or 90 days after authorization is given, whichever is later.

Signature

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