Mandated Schedule

Who is filling out this form? (Select your role)

Attorney's Name

Law Firm / Organization

Attorney’s Phone Number

Attorney’s Email

Probation Officer’s Name

Referring Court

Probation Officer’s Email

What is your relationship to the client?

Your Name (First and Last)

Your Organization (optional)

Your Phone Number

Your Email

Is this for an OWI or DUI charge?

What number of offense is it?

What has the client been charged with or convicted of?

Court where charges are being adjudicated:

Does the client require an evaluation?

For what reason?

Completion Deadline

Will the client be applying for Sobriety Court in the 61st District Court?

Does the client require an interpreter?

Client is referred for (select all)

Continuum of Care Recommendations (GRCS evaluation already completed)

Alcohol Highway Safety Education (1 session)

Anger Management Education program (4 sessions)

Substance Abuse Education Program (4 sessions)

Extended Substance Abuse Education Program (4 sessions + 6 therapy sessions)

Relapse Prevention (Monthly sessions)

Marijuana Education (1 session)

Individual Outpatient Therapy

Client is referred for (select all)

Continuum of Care Recommendations (GRCS evaluation already completed)

Alcohol Highway Safety Education (1 session)

Anger Management Education program (4 sessions)

Substance Abuse Education Program (4 sessions)

Extended Substance Abuse Education Program (4 sessions + 6 therapy sessions)

Relapse Prevention (Monthly sessions)

Marijuana Education (1 session)

Individual Outpatient Therapy

Client is referred for (select all)

Continuum of Care Recommendations (GRCS evaluation already completed)

Alcohol Highway Safety Education (1 session)

Anger Management Education program (4 sessions)

Substance Abuse Education Program (4 sessions)

Extended Substance Abuse Education Program (4 sessions + 6 therapy sessions)

Relapse Prevention (Monthly sessions)

Marijuana Education (1 session)

Individual Outpatient Therapy

What court or county are your charges in?

Do you require an evaluation?

What services are you requesting?

Alcohol Highway Safety Education (1 session)

Anger Management Education program (4 sessions)

Substance Abuse Education Program (4 sessions)

Extended Substance Abuse Education Program (4 sessions + 6 therapy sessions)

Relapse Prevention (Monthly sessions)

Marijuana Education (1 session)

Individual Outpatient Therapy

Additional Information

0/250 max words

Is your report required within 7 days?

Who referred you?

What is your relationship to the person who referred you?

When is your report due?

How would you like to complete your service(s)?

Client's First Name

Client's Last Name

Client's Date of Birth

Client's Phone Number

Preferred Appointment Type

Receive Voicemail?

Yes

Receive Text Message?

By providing your phone number, you agree to receive SMS text messages from Grand Rapids Counseling Services. Message and data rates may apply. Message frequency varies. Reply STOP to opt out, HELP for help.

Yes

Client's Email

May we email you our client newsletter?

Yes

Additional Information

Please use this section to provide any additional information.

0/1000 max characters

GRCS

Grand Rapids
Counseling Services

GRCS

Grand Rapids
Counseling Services

GRCS

Grand Rapids
Counseling Services

GRCS

Grand Rapids
Counseling Services

Request Mandated Services

(616) 988-3433

office@grcounseling.com

Grand Rapids Counseling Services

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