Grand Rapids Counseling Services

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Grand Rapids Counseling Services Registration Form

Name: Email:

Phone: () Charge/Conviction:

OFFICE HOURS

By Appointment
Monday through Friday
8:30 a.m. to 7:00 p.m.
Saturday
9:00 a.m. to 2:00 p.m.
p. (616) 988-3433
f. (313) 899-7087

Payment is expected at time of service
Grand Rapids Counseling Services is located at
2400 Eastern Ave. SE
Grand Rapids, MI 49507
(South-East Corner of Alger & Eastern)
The Rapid bus #4

Dates Date: Time:
Date: Time:

Services Please select a service. Alcohol Highway Safety Education Class | $65.00
*Drivers License Assessment (State of MI) | $200.00
First Time Offenders / MIP Class | $65.00
*Individual Counseling Sessions | $75.00
Marijuana Class | $85.00
*Alcohol Assessment | $100.00
*DOT Substance Abuse Evaluation | $500.00
*Substance Abuse Evaluation | $100.00
Substance Abuse Group - Level I | $240.00
Domestic Violence group | $240.00
High BAC Program | $125.00 p/mo. x 12mos
Other

*You will receive a call within two business days to schedule this service.

Payment Options Cash
Credit Card (Master Card, Visa) add 4%
*Prices are subject to change without notice

Special Instructions

Referred by: Date:

CANCELLATION POLICY: All clients must provide 24 hour advanced notice to reschedule appointments, failure to do so will result in a $50 cancellation fee. Fifteen (15) minutes late for an appointment is considered a cancellation.

Client Signature
Date:

Thank You, Your Registration Form Has Been Sent. Please Print This Page For Your Records.