Client Intake Form

Forms aren’t fun – think “I’m at the beach….I’m at the beach…” – It will only take a few minutes.


To participate in our Alchohal and Drug related courses, please fill out the confidential form below.

We will send you an email when we recieve it. Thanks for choosing ARP!

If Yes, Please Continue to Fill Out the Rest of the Form. If no, you can skip the rest.
Please list an exact date.
Please give a date.
Please list all charges.
List where in the slot below.
List City and State
Please give in format DATE followed by Charge.
If you answered NO, you can skip the next questions.
Your Name - Phone - Email - Address - Relationship to the Client