The Diversion Center Reservation Deposit Form OUR LOCATIONS MARIETTA 2759 Delk Rd. Suite 2425 Marietta, GA 30067 (404) 503-8069 LAWRENCEVILLE 561 W Pike St. Suite 206 Lawrenceville, GA 30046 (404) 781-7468 DULUTH 2702 Duluth Hwy Suite A Duluth, GA 30096 (404) 781-7468 Registration Information*Please contact your local Diversion Center office and set up an appointment BEFORE making your appointment reservation deposit*Client Name* First Last Phone*Email* Deposit* Price: You will be charged a non refundable $25 to hold your appointment. Date of Appointment MM slash DD slash YYYY Message:Terms & Conditions* By making this deposit, you agree to our refund, attendance, rescheduling, and privacy policies. View Our Policies Please Sign Below:*Payment InformationAddress on Card* Street Address City State / Province / Region ZIP / Postal Code Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name EVALUATIONS Alcohol & DrugAlcohol & Drug/Clinical DUIAnger Management CLASSES Level 1Shoplifting/Theft PreventionAnger ManagementFamily Violence InterventionAlcohol & Drug Awareness Values ClarificationPrime For Life®Moral Reconation TherapyParentingVictim Impact Panel OTHER Individual CounselingDrug TestingResources for CounselorsServices for Inmates TweetSharePin
