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Contact Our Licensed Counseling Facility Today

Corporate Office
1501 E. Osborn Rd., Suite 103
Phoenix, AZ 85014
Satellite Location Only
1555 S. Gilbert Rd., Suite 103
Mesa, AZ 85204

(602) 277-2112
information@dynamicliving.net

Order for Screening/Program

Dynamic Living Counseling, Inc. Phone (602) 277-2112 - Fax (602) 294-6636

1501 E. Osborn Rd., Suite 103
Phoenix, AZ 85014

1555 S. Gilbert Rd., Suite 103
Mesa, AZ 85204

Name:

Court:

DOB:

Month

Day

Year

Offense:

Priors:

Address:

Street Address

BAC:

DOV:

City/State/Zip:

Case #:

Phone #:

Start program by:

DL #:

Complete program by:

The undersigned is ordered to participate in the indicated Dynamic Living Program:

DUI/Substance Abuse, Drug, Anger Management, Domestic Violence Screen

LII 8 hour Substance Abuse Education

LII 16 hour Substance Abuse Education

SA, LI, DG, AM, DV Sessions Requires intake

Misd. Domestic Violence Treatment -Intake/26 1.5 hour sessions

Misd. Domestic Violence Treatment -Intake/36 1.5 hour sessions

Misd. Domestic Violence Treatment -Intake/52 1.5 hour sessions

Screening or specific referral for # of sessions is required

Ethics 8 hour class online

Cognitive Restructuring (CR8) Intake/8 1.5 hour sessions

Individual is required to contact Dynamic Living Counseling within 7 days to set an appointment. Appointment must be scheduled within 30 days. Failure to keep appointment and complete program will result in being remanded back to the court. A reinstatement fee will be assessed. By signing this form, client authorizes DLC to release/request information regarding compliance/non- compliance to/from MVD and/or referral court/agency.

Participant Signature

Date

MM slash DD slash YYYY

Judge Signature or Court Representative

Date

MM slash DD slash YYYY

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