Sign Up for a Class – ASCEND COUNSELING LLC

Program Costs:

7 hour D.A.T.E. (Drug & Alcohol Treatment/Education) Program cost is $120

Upcoming Classes:

Gaylord D.A.T.E. – 12/9 (Starting in March we will be offering a 4-5 hour Zoom Alcohol Highway Safety Education Program once every 6-8 weeks.

Fill out the online form below and hit send. You will then be directed to the Thank You/Payment pa

Select class (required):

Date planned/ordered to attend (required):

Please select class location:

Current Legal Charge:

Past Legal Charge(s):

Client Name (First, Middle Initial, Last) (required):

Client Email (required):

Client Phone Number (required)

Date of Birth:

Mailing Address:

City:

State:

Zip:

Probation Officer/Referral Person:

Probation Officer/Referral Agency Phone#:

Probation Officer/Referral Agency Email:

Client Signature:

Date:

Authorization:

By clicking the check box above, I hereby authorize Ascend Counseling to release information to the referring court/probation officer. The nature of the information released will concern my attendance, participation, substance abuse information, when needed offer recommendations for additional referral services. I give permission to Ascend Counseling to communicate with the referral source via email, fax, telephone, & postal mail. This authorization will remain in effect until the purpose for which it was given no longer exists or 12 months – which ever is less.”

Registration form
Registration form (Word format compressed)