621 Scott Street Covington, KY 41011 Phone: (859) 412-4308 Fax: (859) 538-5121 [email protected] The following individual has been referred for services and is instructed to call the above number within seven (7) days of referral date to schedule an assessment. Participant’s Name: _______________________________________________ Date: _________________ Phone Number: ______________________________ Case Number: ____________________________ Foundations for Living Program (Life skills for those in recovery) A psycho-educational group designed to explore, consider, and resolve the underlying struggles that lead to the use of negative coping skills. Anger Management A psycho-educational group for individuals who have allowed their anger and aggression to lead to unhealthy or unlawful behaviors. Men’s Domestic Violence Program (Batterer Intervention) A psycho-educational group designed to support the immediate and long term cessation of violence against intimate partners and family. Women’s Alternatives to Violence Program A psycho-educational group for women who use any combination of control, force, or violence in their intimate relationships. Co-Parenting Seminar A Seminar style class in which separated or separating parents learn how to effectively co-parent their children. Trauma: The Effects of Abuse & Neglect on Children A seminar discussing the social, emotional, and physical effects of trauma on each developmental level of childhood and its lasting effects on adulthood. Referring Judge/Agency: __________________________________________________________________ Comments: __________________________________________________________________________________ _________________________________________________________________________________________________ White Copy – Court | Yellow Copy – Participant | Pink Copy – Mainspring Wellness
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