Counseling Referral (Municipal Court)
Client Information: Client Name:   Phone #:
Case Numbers: (if applicable) C-   - or
(DHS Only) KK: Date of Sentence: (if applicable) Date of Birth:

Referral Source Information:
(Name of person who needs progress reports, incident reports, UA results, etc.)
Referral Name:   Work Number:   Fax Number:
Referral Agency:
Email Address:        
 
Payment/Fee Options: (Check only One) Pay Privately Apply for Financial Assistance
 
Recommended Services: (Check all services you would like the client to participate in)
COURT RELATED ASSESSMENT SERVICES:
DUI Assessment: English Spanish Consists of one 2 ½-hr. session.
Substance Abuse Evaluation: AAP- Prostitution Family Court Criminal Court Other

DUI SERVICES:
(Services help client get his/her drivers license back after a DUI)
10 Hour ADSAC (DUI) School English Spanish Consists of three 3 ½-hr. sessions.
24 Hour ADSAC (DUI) School English Spanish Consists of twelve 2-hr. sessions.
DUI Outpatient Programs 6-week program
  12-week program
Victims Impact Panel - Consists of one 2-hr. session, facilitated by (MADD) Mothers Against Drunk Driving
Intensive Outpatient DUI Programs - 6 week program (9 hours per week) and 6-weeks of aftercare.  Individual, group, family and substance abuse education services provided.
Relapse Prevention/Aftercare Programs- 6-week DUI Aftercare Program

COURT RELATED/PROBATION TREATMENT SERVICES:
   
(BADD)- Basic Alcohol/Drug Diversion- (12 week First Time Alcohol/Drug Offender Program)
(RID)- Reducing Intoxicated Drivers- (12 week Repeat DUI Offender -Recidivism Reduction Program)
(DDDT)- Do Drugs Do Time- (12 week Repeat Drug Offender -Recidivism Reduction Program)
Criminal Thinking (lmpulse Control) Program - 12 week program for adolescents and adults, designed to challenge and correct irresponsible criminal thinking and behavior, 1-1 ½ hours per week
Anger Management/Coping Skills Program-12 week program for adolescents and adults, 1-1 ½ hours per week. 

SUBSTANCE AND CO-OCCURRING ABUSE TREATMENT SERVICES:
Substance Abuse Assessment English Spanish Consists of one 2 ½-hr. session.
Early Intervention Programs- 6-8 week substance abuse education program for adults and 6-8 week substance abuse education program for adolescents.  Random Drug Testing provided (if UA referral form completed)
Outpatient Adolescent Programs - 6-12 week program for adolescents. Individual, group, family and substance abuse education services provided.  Self-help meeting attendance and random drug testing is required. 
Intensive Outpatient Adolescent Programs - 6 week program (6-8 hours per week) and 6-weeks of aftercare.  Individual, group, family and substance abuse education services provided.  Self-help meeting attendance and random drug testing is required. 
Outpatient Adult Programs- 6-12 week program for adults. Individual, group, family and substance abuse education services provided.  Self-help meeting attendance and random drug testing is required. 
Intensive Outpatient Adult Programs - 6 week program (9-10 hours per week) and 6-weeks of aftercare.  Individual, group, family and substance abuse education services provided.  Self-help meeting attendance and random drug testing is required.   
Relapse Prevention/Aftercare Programs 6-week program
  12-week program

SPECIALIZED TREATMENT SERVICES:
(SFP) - Strengthening Families Program - SFP is a “Free” outpatient program presented in a 14 week format with highly structured, consecutive weekly sessions, each lasting approximately 2 hours.  Which is aimed at Treating the Whole Family” (Parents and Children), to help heal, implement a recovery based model and assist in family reunification for your clients. 
"Amethyst House" (Sober House) Programs - 90 day to 1 year sober living and outpatient treatment.  Individual, Group, Family and Aftercare Services Provided.  Self-help meeting attendance is required.  Random Drug Testing required. 
Impaired Professionals Program - 12-week to 6 month outpatient treatment set up for working professionals (attorneys, nurses, doctors and other professionals who are struggling with addiction and desire a life of sobriety.  Individual, Group, Family and Aftercare Services Provided.  Self-help meeting attendance is required.  Random Drug Testing required. 
Opiate Addiction Program - 12-week to 6 month intensive outpatient medication assisted treatment program set up for individuals who are struggling with opiate addiction (lortab, heroin, oxycontin, oxycodone, etc).  Individual, Group, Family and Aftercare Services Provided.  Medication assistance (Dr. visits required).  Self-help meeting attendance is required.  Random Drug Testing required. 


LEVEL OF IDENTIFIED RISK:
(Level checked indicates the risk of relapse/continued use or other behavioral/family problems)

Low Risk - (Risk is minimal) Early Intervention referral is indicated
Medium Risk - (Risk is moderate) Extended Outpatient referral with additional family services is indicated
High Risk - (Risk is extreme) Intensive Outpatient referral with additional family services is indicated
Case history, evaluation results, or comments supporting assigned level of risk:
 
Please add any additional information below:



To prevent our website from being spammed please enter the code below.
Enter Code: