REFERRAL FORM

Arizona Consulting And Counseling Services Adult Probation Referral Form

Please send Arizona Consulting And Counseling Services your information. We will happily get back to you as soon as possible.

Date:
Client to Contact Agency By:
Client Name:
Phone:
Referring Agency: Maricopa County Adult Probation
BCB
WRC
PCS
Northport
Durango
SCTD
Probation Officer:
Office:
Phone:
Referred For:
Individual Counseling ($65.00 per Session)
DUI/Substance Abuse Screening for Appropriate Group ($65.00)
Relapse Prevention (16-20 Treatment Groups)
Anger Management (16 Weeks)
Domestic Violence/PEACE Program (36/52 Weeks)
Mental Health Evaluation ($100.00)
MVD Evaluation ($100.00, In State / $125.00, Out of State)
8-Hour Substance Abuse Education (One Day Only $75.00)
16-Hour Alcohol/DUI Education (Two-Days Only $100.00)
Cognitive Lifeskills Program ($20.00 Per Group, 8 Session Program) REQUIRES INTAKE
Parent Education ($25.00 Per Group, 4 Session Program) NO INTAKE REQUIRED
Avondale Office
Surprise Office
Chandler Office
Peoria Office


Comments: I hereby give my consent for release of any pertinent information for your treatment enrollment/progress to Arizona Consulting & Counseling Services (ACCS) to and from Maricopa County Adult Probation Department. By signing, I agree that each of the above agencies can exchange information related to my treatment that is deemed necessary.

Client Signature: Date:
 
Surprise Office:
15535 N. Reems Rd Suite 125-23 S
Surprise, AZ 85374
Avondale Office:
1481 N Elisio Felix Way, Suite 100
Avondale, AZ 85323

Chandler Office:
283 N. Arizona Avenue, Suite 1/2
Chandler, AZ 85225
Phone: 480-732-0011
Fax: 480-732-0001
 Peoria Office:
9162 West Cactus Road, Suite B
Peoria, AZ 85381
Phone: 623-776-7766
Fax: 623-776-7767