Schedule Request Form - AACS Counseling

Request a Call Back

Schedule Request Form

Please complete the form below after making your payment. Our administrative team will review your information to ensure a smooth scheduling process and that the correct evaluation type is arranged.

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Email Address(Required)

Phone Number(Required)

Home Address

Street Address State / Province / Region ZIP / Postal Code

Preferred Contact Method(Required)

Best Day and Time to Contact You for Scheduling:(Required)

Specified Time(Required)

What is the purpose of this evaluation? (Choose all that apply)(Required)

Court Ordered

Lawyer/Attorney Requested before court

Condition of Probation

Employment Requirement

Relicensing

Post-DUI Conviction Requirement

Divorce Court

Child Custody/Family Court Case

Personal or Self-Assessment

DOT Violation

Are you here because of a DUI arrest?(Required)

Is your DUI case still pending (Do you have an upcoming court date?)(Required)

Have you been convicted (found guilty) of a DWI, OUI, OWI, OVI, DWAI, DUAC, or any other similar impaired driving offenses?(Required)

Are you currently involved in a child custody or divorce case?(Required)

Are you seeking a return-to-duty clearance under DOT regulations?(Required)

Additional Information

Please provide an overview of your current situation. Include any specific details we should be aware of:(Required)

Share any relevant details that might help us assist you better.

Name payment is under(Required)

If your payment was processed under a name that is not yours, please assist us in locating it by providing the name associated with your payment:

Agreement and Submission

By submitting this form, you agree that all information provided is accurate and truthful to the best of your knowledge.

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800-683-7745

( virtual telehealth services )

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State:

City:

Evaluation Type:

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Request a Call Back

Name(Required)

First Last

Email(Required)

Phone Number(Required)

Subject(Required)

Message(Required)

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State:

Evaluation Type:

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Request a Call Back

Name(Required)

First Last

Email(Required)

Phone Number(Required)

Subject(Required)

Message(Required)

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State:

City:

Class Type:

By providing your phone number and submitting this form you are consenting to be contacted by SMS text message. Message and data rates may apply. Reply STOP to opt out of further messaging; for more information, reply HELP. Additionally, you confirm that you have read and agree to our Privacy Policy and Terms of Service.

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State:

City:

Class Type:

By providing your phone number and submitting this form you are consenting to be contacted by SMS text message. Message and data rates may apply. Reply STOP to opt out of further messaging; for more information, reply HELP. Additionally, you confirm that you have read and agree to our Privacy Policy and Terms of Service.

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