CLIENT INTAKE FORM
 
 

 

Fill Out Below INTAKE FORM and Save $50.00 Intake Meeting
In Person - Saves/Time/Gas/Stress/Money

For Cell Phone Users (no internet access) call Richard 678-576-1913
to make arrangements.

A.) VOLUNTEER & COURT ORDERED PARTICIPANTS

ATLANTA ANGER MANAGEMENT INTAKE FORM

Atlanta Anger Management

For Participants Who Need An Anger Management Class With Court Ordered Check Box
Sign Up for 8 Hours Of Classes.

One Saturday or Sunday Class = 8 Weeks Of Classes In One Day
One Hour A Week Classes Takes 8 Weeks = 8 Hours/8 Classes
Two Hours A Week Classes Takes 4 Weeks = 8 Hours/4 Classes = 8 Weeks Of Classes

  • For Participants Who Need An Anger Management Class
    With Court Ordered Specified Number Of Hours:
  • 6 Hours
  • 12 Hours
  • 16 Hours
  • Call 678-576-1913 For Information.




    Pay At The Class by Cash, VISA, MC, AMEX.

    Check Class Dates:
    Saturday And Sunday Classes
    Week Night Classes

    Mark Your Choice Of Class Time Or Individual Private Session
Anger Management Saturday Group Classes 8:55AM to 6:00PM One Day
$240/8 Hours = 8 Weeks of Classes - You Receive Your Court Papers At End Of Class


Anger Management Sunday Group Classes 8:55AM to 6:00PM One Day
$240/8 Hours = 8 Weeks of Classes - You Receive Your Court Papers At End Of Class


Date


12 Hour Participants Can Take A One Day Saturday Class And Add A Four Hour Class That Suits Your Schedule Monday through Friday.

Mark Your Choice Of Class Time Or Individual Private Session



Anger Management Group Tuesday Night Classes 6:30PM to 7:30PM $35/Class

Anger Management Group Tuesday Night Classes 7:30PM to 9:30PM $70/Class


Anger Management Group Wednesday Night Classes 6:30PM to 7:30PM $35/Class

Anger Management Group Wednesday Night Classes 7:30PM to 9:30PM $70/Class


Anger Management Group Thursday Night Classes 6:30PM to 7:30PM $35/Class

Anger Management Group Thursday Night Classes 7:30PM to 9:30PM $70/Class


Individual Private One-On-One Session $70/Hour

Accelerated One Day Anger Management Course For Individuals - Mon <-> Fri. $485

VIP Concierge Service - Richard Comes To You. Inquire For Cost/Availability

A.) YOUR INFORMATION

Your Name


Nick Name


Address1


Address2


City


State

Zip Code


Phone


E-mail Address


Do You Check It


Date Of Birth


Age


Gender


Marital Status


# of Dependants


Employment Status


Student Status


Alcohol Use


Drug Use


Diagnosed With Any Physiological Disorder?


If Yes, What?


Prescription Medications Taken


Any Priors (Been Arrested Before?)


If Yes, List What and When


Reason For Attending

 

How Did You Find Us?



B.) COURT ORDERED PARTICIPANTS

YOUR INFORMATION

Case #, Citation #, Warrant Number


Offense (What You Were Charged With and When?)

REFERRING PARTY INFORMATION
This is the person you are going to present your final paperwork to. It might be your Probation Officer, Judge, Solicitor General, Attorney, Employer, HR Department.

This information will appear on Letter Of Enrollment, Progress Reports if Required, and Final Graduation Papers.

Name


Title


Company Name


Name Of Court


Address1

Address2


City



State


Zip Code


Phone


Fax


E-mail Address


COMMENTS



  

 

ATLANTA ANGER MANAGEMENT
ANGER MANAGEMENT CLASSES

No Enrollment Fees.
No Drop Ins.
By Approval.


Court Ordered Anger Management Classes - Atlanta
Volunteer Anger Management Classes - Atlanta
Employer Mandated Anger Management Classes - Atlanta


We look forward to helping you! - Richard


Questions?
Call Richard at 678-576-1913
with your court papers available.

 
 
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