MDOC Agent Referral Form

MDOC Agent(Required)

First Last

MDOC Client #(Required)

MDOC Office(Required)

Offense(Required)

Client Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Outpatient Programs

Outpatient Relapse Prevention Program - $50 Assessment and $20/week for weekly groups

Assessment Only - $75

Assessment $75 - Client Must Follow Recommendations

10 Week Alcohol, Marijuana, and other Drugs - $200 (10 sessions, utilizes interactive journal)

CBT - Concentrate on Better Thinking - $160 (8 Sessions, utilizes interactive journaling)

Anger Management Multi-Session (Berkley/Livonia/Waterford) - $150 for 6 Weeks

Anger Management Multi-Session (Berkley/Livonia/Waterford) - $300 for 12 Weeks

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 with Reduced Rates for MDOC Clients

M20 Alcohol Weekend Education - $100 / 13.0 hrs

M21 Alcohol One Day Education - $60 / 6.5 hrs

M24 Marijuana One Day Education - $60 / 6.5 hrs

M25 Anger Management Weekend - $100 / 13.0 hrs

M26 Anger Management One Day - $60 / 6.5 hrs

M27 Retail Fraud One Day - $50 / 4.0 hrs

M28 Retail Fraud 5 session - $100 / 10.0 hrs

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

Max. file size: 50 MB.

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