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Services Offered
Speaking Engagments
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Group Home Page
R.E.S.T.O.R.E-Healthy Relationships
P.R.O.C.E.S.S- Emotional Regulation Group
REDEEM
All Group Registration Form
Shelby County
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Home
About Us
Contact
Services Offered
Speaking Engagments
Therapeutic Groups
Group Home Page
R.E.S.T.O.R.E-Healthy Relationships
P.R.O.C.E.S.S- Emotional Regulation Group
REDEEM
All Group Registration Form
Shelby County
Toggle navigation
Date of Referral
*
Client's DOB
*
Location for testing
*
Client's Address
*
Billing Name
*
FACTS number
*
Case Number
*
Reason for Referral
*
Person making referral name and number
*
Social worker name and number
*
Email address
*
CFA attached
*
YES
NO
ISP attached
*
YES
NO
Check All That Apply
*
Psy Evaluation
In-home
Anger Managment
Parenting
Couples Counseing
Family Counseling
Individual Counseling
Substance Abuse
Domestic Violence
Select a Location
*
Montgomery
Birmingham
Third Choice
County
*
Submit
Please Note!
Services will begin once the 1878 is received.