To leave a referral, please fill out the form below. Any additional information, questions, or remarks can be entered in the comment section. Filling out the form completely will help expedite the referral. When finished click the submit button and one of our qualified personnel will contact you shortly. If you have any trouble submitting this form please e-mail Kenneth@behavioraltreatmentproviders.com. Referred By Type of Referral Voluntary Court Ordered Stay of Execution Agreed Order Probabtion Name/Probation Offier Contact Phone E-mail Client Information Name Phone Social Security Number Date of Birth Address City State Zip Warrant # Judge Program Select Program A&D treatment: Low Intensity Outpatient Program (Gallatin Pike) 16 Sessions, Must attend 2 times a week Anger Management MRT – 8/12/16 Week @ Gallatin Pike Brief Cognitive Intervention Anger Management Program @ Gallatin Pike Brief Cognitive Intervention Shoplifting Program @ Gallatin Pike Domestic Violence MRT – 12/ 16/26/52 Week (Bell Rd) Domestic Violence MRT – 12/16/26/52 Week (West End) Domestic Violence MRT – 12/16/26/52 Week @ Gallatin Pike Domestic Violence MRT – 12/16/26/52 Week Women’s Program (Gallatin Pike) Dual Domestic Violence MRT – 12/16/26/52 Week @ Gallatin Pike DUI School @ Gallatin Pike DUI School @ Glencliff Presbyterian Church DUI School @ The Brentwood Church of the Nazerene DUI/ Alcohol & Drug Assessment John School @ ST Ann's Episcopal Church John School Number of Weeks Comments