REGISTRATION FORM

VIRTUAL & IN-PERSON SERVICES OFFERED

Todays Date

Full Name

Phone

Date Of Birth

Email

Assessment (Required) $100

Service Request:

Anger Management - 8 Weeks - $200 Session Fee - $10 + S/H = $210

Gang Activity - 10-12 Weeks - $250 Session Fee - $25 + S/H = $275

Job Readiness - 6 Weeks - $150 Session Fee - $9 + S/H = $159

Relapse Prevention - 8 Weeks - $200 Session Fee - $10 + S/H = $210

Mental Health - 24 Weeks - $600 (Private Insurance) - $25 + S/H = $625

MRT - 10-12 Weeks - $250 Session Fee - $25 + S/H = $275

Parenting Skills - 12 Weeks - $250 Session Fee - $15 + S/H = $265

Substance Use Disorder - 6-8 Weeks - $300 Session Fee - $25 + S/H = $325

Shoplifting - 12-24 Weeks - $600 Session Fee - $25 + S/H = $625

Referral Source

Thanks For Registering! Allow 24-48 Hours For Email Verification.

(678)-698-9596

Martin Luther King, Jr. SW Atlanta, GA 30310

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