Phase 1 Group Selection

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)

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.

Tuesday at 7:30-9:00 PM (G101)

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.

Please confirm you have watched the orientation video at www.rockvilleapp.com/start.

I have watched the orientation video and understand the program rules.

Please check here if you have been referred by PRETRIAL SERVICES

pretrial referral

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