Registration

Register

To register for Drug Offender Education Program, DWI Basic Education, DWI Repeat Offender Program, Brief Intervention, or Marijuana Intervention please submit the following form.

Fields with an asterisk (*) after them are required.

Please Note:

This form only registers you for the class. You must pay for the program in full, or pay for the registration fee and first class session to be considered enrolled in the program. You will not be guaranteed a seat in the class until you have paid the required fees for enrollment. After you complete the registration form, you will be given the option to pay the required fees for the program to complete your enrollment.

Client Information

First Name: *

MI:

Last Name: *

Email: *


Phone #: *	( )	-

Can we leave a message at this number? YesNo

Date of Birth *

Address

Street Address *

Address continued

City *

State *

Zip *

Program Enrollment

Please select the office location you will be attending to complete the program. * Fort Worth Office - 6320 Brentwood Stair Rd, Fort Worth, TX 76112
Arlington Office - 605 E Border St, Arlington, TX 76010

Please select the program you would like to pre-register for at our Fort Worth Office. *

Please select the program you would like to pre-register for at our Arlington Office. *

Select a Date *

Additional Information

Referral

Who referred you to CTC?

Name

Name of Agency


Phone #: *	( )	-

Are you currently on probation or parole? * YesNo

Would you like for us to share your program information with your referral source? * Yes, please share my information as described above.
No, I want my information to remain confidential.

Please confirm whom we should communicate your attendance and/or program status

Name * Name of referral

Telephone *

Agency

By entering your initials into the box provided below you are providing The Center for Therapeutic Change a digital signature that gives your consent for the Center for Therapeutic Change to release information to the designated referral source regarding the program you have enrolled in using this web form. Once you have submitted your initials representing your digital signature, your consent to release information will remain effective for exactly one year and can only be revoked by presenting, in writing, to The Center for Therapeutic Change a request to revoke consent. * By placing my initials in the box below, I authorize the Center for Therapeutic Change to contact both myself and/or the referral source I have listed above regarding my enrollment and participation.

CTC will attempt to contact you via telephone &/or by mail to remind you of your scheduled appointment.

Need assistance with this form?

Report abuse