Oakland County MDOC Referral Form

CALL ETRS (800) 213-3877 to schedule your class or register online at www.etrsmichigan.com.

Probation Agent / Parole Officer Name(Required)

Probation Agent / Parole Officer Email(Required)

Probation Agent / Parole Officer Phone(Required)

MDOC Client #(Required)

MDOC Office(Required)

Offense(Required)

Participant Name(Required)

First Last

Date of Birth(Required)

Participant Email(Required)

Participant Phone(Required)

Outpatient Programs

CBT/Positive Options Program: $240/8 sessions (Virtual Option)

Economic Crime/Positive Options Program (Retail Fraud/Theft): $135/4 sessions (Virtual Option)

Domestic Violence 26 Weekly Sessions (Virtual Option)

Evaluations

Substance Abuse Evaluation: $165

Mental Health Evaluation: $225

If you are recommending an Oakland County MDOC-Funded Program, please upload the BIR below.

Max. file size: 50 MB.

If you are recommending an Oakland County MDOC-Funded Program, please upload a Compass Bar Chart below.

Max. file size: 50 MB.

By what date does the Participant need to finish the program(s) checked above?