TRAVIS COUNTY COUNSELING & EDUCATION SERVICES
CES Referral Form
Referring Agency Instructions:
1. Fill out information below pertaining to your client and check appropriate services.
2. Once completed send CES Referral form to ces.Mail@traviscountytx.gov or fax to
(512) 854-9146.
____________________________________ ___
_________________________________
CLIENT NAME DOB
__________________________________ ____________________________________
OFFENSE CAUSE#
___________________________________ ____________________________________
ATTORNEY Name - CONTACT INFO Probation Officer & UNIT/OTHER
*Fees are due at the time of assessment $55 or class registration (see menu of services on back) payable only by
CREDIT CARD, MONEY ORDER OR CASHIER’S CHECK made out to CES. NO PERSONAL CHECKS or CASH.*
CES SERVICES:
(CHECK if applicable)
_____________
a. For a Family Violence Charge needing either an Alcohol/Drug or a Family Violence assessment:
• The assessments (approximately 2 1/2 to 3 hours
) are conducted at the Intake Office located at 1010 Lavaca, 2
nd
floor
(map on back). Monday through Thursday from 7:30am to 2:30pm or Friday 7:30am to 11am. THE EARLIER YOU
ARRIVE THE MORE LIKELY YOU ARE TO BE SEEN. No appointment is necessary. Cost of assessment is $55.00
due at the time of assessment.
BRING THIS REFERRAL FORM WITH YOU. Bring any other paperwork related to your offense with you i.e.
Probation Papers; Bond release paperwork; Protective Order, etc.
(CHECK if applicable)
b. For an Alcohol and other Drug (AOD) Assessment (NON-Family Violence Charge)…….…____________
The AOD assessments (approximately 2 to 3 hours) are conducted at the Service Center located at 5501 Airport
Blvd., Suite 102 (map on back). Monday through Thursday from 7:30am to 3:30pm or Friday 7:30am to 11am. THE
EARLIER YOU ARRIVE THE MORE LIKELY YOU ARE TO BE SEEN. No appointment is necessary. Cost of AOD
assessment is $55.00 due at the time of assessment.
BRING THIS REFERRAL FORM WITH YOU. Bring any other paperwork related to your offense with you i.e.,
Probation Papers; Bond release paperwork; Protective Order, etc.
(CHECK if applicable)
c. For CES Classes ONLY (Select from Class Menu on the back)…………………………………____________
ALL CLASSES ARE HELD AT 5501 AIRPORT BLVD. SUITE 102
• Call (512) 854-9540 (M-F, 8-5 p.m.) within 24 hours of receipt of this form for class information. If registering for
an education or youth class only, you will be scheduled into the class at the time you call CES. All education class fees
are payable at the time of your class. A completion certificate will be issued to you at the end of the class if all fees have
been paid. For more information about our classes and services visit our website
at: https://www.traviscountytx.gov/counseling-education
• BRING THIS REFERRAL FORM WITH YOU. Bring any other paperwork related to your offense with you i.e.,
Probation Papers; Bond release paperwork; Protective Order, etc.
• If registering for an AOD class only, you will need to go to the Service Center located at 5501 Airport Blvd., Suite 102
(map#1 on back) Monday through Thursday from 8am to 7pm or Friday from 8am to 3pm. Class fees are located
on the back of this form and required at the time of registration.
WRITE IN APPOINTMENT / CLASS INFORMATION BELOW:
DATE: __________________ TIME: _____________ LOCATION: _____________________________
09/18
