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Please complete the form below. We will contact you to verify we have received your referal submission. By submitting this form you agree to the following below:

  • To appear at the PASS office during posted business hours.
    • Hours are Monday - Friday 6:00 - 8:30 AM and from 6:00 - 8:30 PM;
      • Saturday and Sunday 6:00 - 8:30 AM ONLY.
  • To arrive 30 minutes before closing time for the initial intake / screen.
  • To bring picture ID for the initial intake / screen.
  • To pay for all services rendered prior to being screened. We accept cash, debit card, and credit card.
  • To bring proof of any prescriptions.
  • To comply with all conditions of PASS screening program
  • That you understand if you do not comply, the court or referring agency will be notified immediately.

Please include the following information in your message below:

  • Client / Defendant Name
  • Client / Defendant Date of Birth
  • Client / Defendant Phone Number
  • Probation Officer / Referring Agent Name
  • Judge / Court / Referring Agency
  • Probation Officer / Referring Agent’s Phone Number
  • Current Offense
  • Case Number
  • Date to begin Program
  • Other Reporting Requirements / Comments