DUI Education Classes Referral | Restoration Behavioral Health Systems

DUI

Date*

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Phone*

Email

DUI

Is this a self referral?*

Yes

No

Referring Person's Name

Referring Person's Phone

Relationship

Email

Do you have an attorney?*

Yes

No

Attorney Name

Attorney Phone

Are you on probation?*

Yes

No

Probation Agents Name

Probation Agents Phone

DUI

Date of last arrest? (if known)

Date of next court hearing? (if known)

Is your driver’s license currently valid?*

Yes

No

Number of Arrests in last 30 days*

Number of Arrests in Last 12 mos*

DUI

Terms

Referral Authorizations

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Restoration Behavioral Health Systems. I authorize payment of medical benefits to David’s Lost Clinical Services. I also understand that payment of is my responsibility and Restoration Behavioral Health Systems has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection.

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Restoration Behavioral Health Systems. I authorize payment of medical benefits to David’s Lost Clinical Services. I also understand that payment of is my responsibility and Restoration Behavioral Health Systems has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Restoration Behavioral Health Systems. I authorize payment of medical benefits to David’s Lost Clinical Services. I also understand that payment of is my responsibility and Restoration Behavioral Health Systems has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection.

Typing my name below serves as my digital signature.

Referral Authorizations*

I agree to the referral authorization terms

Digital Signature*

Name

This field is for validation purposes and should be left unchanged.

DUI Education Referral Form

DUI

DUI

DUI

DUI

DUI

DUI

Terms

Referral Authorizations

Referral Authorizations