3660 MARKET STREET CLARKSTON, GA 30021
Office (404) 298-9005  Fax (404) 298-0046
Website www.positivegrowthinc.org  Email [email protected]
PGCC REFERRAL FORM
CLIENT INFORMATION
Date:
Probationer’s Name:
Home Number:
Alternate Number:
PROBATION INFORMATION
Offense:
Judge:
Probation Officer (PO):
PO Phone Number/Fax:
PO Email Address:
PROGRAM SERVICES REQUESTING
 Domestic Violence Intervention Program
 DUI Clinical Evaluation
 Anger Management Program # of session’s ______
 Alcohol and Drug Education Group
 Caring Dads: A fatherhood Parenting Class
 DUI Risk Reduction Program
 Non- DUI Alcohol & Drug Evaluation
 ASAM Level I Treatment Group
 Parenting Education Class # of session’s ______
 Value Clarification-Theft-Shoplifting Course
 Individual, Group, Family Couples Counseling
 Other: __________________________
You have been ordered by the Court to attend and complete one or more of the Court Mandated Programs listed
above as a condition of your Probation. Please contact Positive Growth Counseling Center IMMEDIATELY to
schedule an Appointment for the selected program (s) listed above.
YOU WILL NEED TO CONTACT:
Joseph Arnold  404-549-1313 [email protected]
Office (404)298-9005  Fax(404) 298-0046
Appointment must be scheduled by: ______________________________________________________
PARTICIPANTS ARE REQUIRED TO PAY EVALUATION FEE AT THE TIME OF REGISTRATION. THE
WEEKLY GROUP FEE IS TO BE PAID IN THE FORM OF CASH OR MONEY ORDER ONLY. All other
services vary in registration requirements, # of sessions and pricing. Your probation officer will have dates, times,
fees and completion requirements for any of the other above services.
Failure to schedule appointment and complete the recommendations may and can result in a warrant for your arrest
or other court action being initiated.
_____________________________________
Probationer Signature
________________
Date
All classes &
assessments are
now available in
_____________________________________
Probation Officer’s Signature
________________
Date
Spanish
Traveling 285 North Exit to Church Street (Exit 40). Turn right off the ramp and travel through (1) traffic lights, at the stop sign turn left onto Market Street crossing over railroad tracks through traffic light.
Positive Growth Counseling Center is the grey building on the right. Traveling 285 South Exit to E. Ponce Deleon Ave (Exit 40). Turn left off the ramp and travel through (2) traffic lights, at the third traffic light
turn left onto Market St. Positive Growth Counseling Center is the grey building on right. MARTA- If you are riding MARTA, you can ride the #120 bus from Avondale Station (EAST/WEST). Exit bus at E.
Ponce Deleon Ave. and Market Street; cross the street toward Clarkston Motors, Positive Growth Counseling Center is the grey building on the right; 3660 Market Street
(Update 01/04/2010)