Fatino Counseling Services
Enrollment
Home
Enrollment Request!
Complete this form to refer your client for treatment.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Address
*
City, State, ZIP
*
Phone Number
*
Email
*
We will never share your email with anyone.
What Program are you Interested In
*
Assessment – SUD
Assessment – BIP
Assessment – Anger Management
Assessment – Other
Batterers Intervention Program (BIP)
Drug Testing
Substance Abuse
Court Appearance
Mental Health Services (MHS)
Mental Health
When would you like to start?
*
MM/DD/YYYY
Referer Name
*
First and Last Name
Please Enroll