NIC Enrollment Inquiry
Name
*
First Name
Last Name
Birthday (00/00/0000)
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Name of Probation Officer
*
I need to attend an intake for:
*
Men's Domestic Violence
Women's Domestic Violence
LGBTQAI+/Same Sex Domestic Violence
DUI/DWAI
Subtance Use (Non DUI)
MRT
Anger Management, Parenting, or DBT (weekly group)
Re-enrollment (I have been a client within the last 6 months)
Submit
Should be Empty: