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FLSE Information Request Form
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Email
*
Your email
Please provide your legal name.
*
Your answer
Which service/program are you interested in?
*
Free 10-minute Consultation
Anger Management Education
Court-Mandated Anger Management Education
Abuse Intervention
Relationship Education (Individuals)
Relationship Education (Families/Groups)
Community Issues Workshop
Family Life Workshop
Workplace Abuse Intervention Workshop
Required
If sessions are court-mandated, please provide name and contact info of probation officer or social worker:
Your answer
If sessions are court-mandated, how many sessions are required:
Your answer
Will you need a certificate and status reports?
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Yes
No
Maybe
What is your desired start date?
MM
/
DD
/
YYYY
What is your deadline to complete the program?
MM
/
DD
/
YYYY
Please provide your phone number.
*
Your answer
Please provide your email address.
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Your answer
Thank you for your interest. We will respond shortly.
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