Courts & Referral Sources Need to refer a client? Simply click on the link below, complete the form, and hit send. We will do the rest! Order for Screening/Program Dynamic Living Counseling, Inc. Phone (602) 277-2112 - Fax (602) 294-6636 1501 E. Osborn Rd., Suite 103Phoenix, AZ 85014 1555 S. Gilbert Rd., Suite 103Mesa, AZ 85204 Name:Court:DOB:MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Offense:Priors:Address: Street Address BAC:DOV:City/State/Zip:Case #:Phone #:Start program by:DL #:Complete program by:The undersigned is ordered to participate in the indicated Dynamic Living Program:DUI/Substance Abuse, Drug, Anger Management, Domestic Violence ScreenLII 8 hour Substance Abuse EducationLII 16 hour Substance Abuse EducationSA, LI, DG, AM, DV Sessions Requires intakeMisd. Domestic Violence Treatment -Intake/26 1.5 hour sessionsMisd. Domestic Violence Treatment -Intake/36 1.5 hour sessionsMisd. Domestic Violence Treatment -Intake/52 1.5 hour sessionsScreening or specific referral for # of sessions is requiredEthics 8 hour class onlineCognitive Restructuring (CR8) Intake/8 1.5 hour sessionsIndividual is required to contact Dynamic Living Counseling within 7 days to set an appointment. Appointment must be scheduled within 30 days. Failure to keep appointment and complete program will result in being remanded back to the court. A reinstatement fee will be assessed. By signing this form, client authorizes DLC to release/request information regarding compliance/non- compliance to/from MVD and/or referral court/agency. Participant SignatureDate MM slash DD slash YYYY Judge Signature or Court RepresentativeDate MM slash DD slash YYYY Client Referral Form
