Excel Treatment Homepage

Please fill out the enrollment form and we will contact you for an appointment as quickly as possible. All material is held strictly confidential.

Enrollment Form

Evaluator/Probation Officer/Referral Source:
Attorney Name:
Alcohol/Drug related?:
County of Charge/Conviction:
Date of Offense:	//
Date of Sentencing:	//
Reason for admission:

Client's name:
Client's address:
Client's home phone:
Client's work phone:
Client's birthdate:	//
Client's age:
Client's sex:

Employer:
Occupation:
Spouse's occupation:
Emergency contact:
Relationship to client:
Phone #:
Contact's address:

Which services are you interested in?
Level 1:
Level 2 Ed:
Level II Therapy:
TGGRS Treatment:
Anabuse Program:
UAs/Breath Program:
1-1 sessions:
Relapse Prevention: