Phase 1 Group Selection Form

Phone Number

Email (subject to terms available at www.rockvilleapp.com/start)

Preferred method of contact:

Phone

Email (subject to terms in HIPAA acknowledgement form at rockvilleapp.com/start)

Terms & Conditions

I have watched the orientation video at www.rockvilleapp.com/startand understand the program rules.

I understand that I may be removed from a group session and counted absent if I do not follow the program rules.

I understand that I may not miss more than 6 classes for any reason.

I understand that I am responsible to pay $20 for any session attended up until the time I submit proof of income

Please check here if you have been referred by PRETRIAL SERVICES

pretrial referral

Monday at 5:30-7:00 PM (G103)

I would prefer this time.

I can make this time if I have to.

I cannot make this time.

Monday at 7:30-9:00 PM (G104)

I would prefer this time.

I can make this time if I have to.

I cannot make this time.

Saturday at 8:00-9:30 AM (G106)

I would prefer this time.

I can make this time if I have to.

I cannot make this time.

We will contact you when we have a space available for you.