MDOC Agent Referral Form

Probation Officer/Agent(Required)

Probationer Email(Required)

MDOC Client #(Required)

MDOC Office(Required)

Offense(Required)

Client Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Outpatient Programs

Outpatient Relapse Prevention Program - $100 Assessment and $30/week for weekly groups

Assessment Only - $100

Wayne County MDOC-Funded Programs (no cost to offender)

Men’s Domestic Abuse – 1 Day Orientation and 26 weekly 90-min follow-up sessions - NO COST TO WAYNE CO. FELONY DV OFFENDERS

Wayne County Felony OWI Offenders - Outpatient substance Abuse Program - 18 weeks - NO COST TO WAYNE CO. FELONY OWI OFFENDERS

ETRS Programs

M20 Alcohol Weekend Education - $200 / 13.0 hrs

M21 Alcohol One Day Education - $120 / 6.5 hrs

M25 Anger Management Weekend - $200 / 13.0 hrs

M26 Anger Management One Day - $120 / 6.5 hrs

M27 Retail Fraud One Day - $120 / 7.5 hrs

Other Programs

Mental Health Evaluation - $200

M28 CBT: Concentrate on Better Thinking/Positive Options - $200 (8 sessions, utilizes interactive journaling)

If you are recommending a Wayne County MDOC-Funded Program, please upload BIR below.

Max. file size: 50 MB.

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