Shoplifting Intervention

Shoplifting Intervention Registration Form

Use the form below to register for the Shoplifting Intervention program.

Tele-health Services

Most of our services are available to be completed remotely via a telehealth session. This appointment can be completed with most devices that have a camera and microphone, including a laptop computer, Android phone, Apple iPhone and most tablets.

Appointment Information

Enter the information below as it would appear on your Driver's License or State Issued Photo ID. If you have a DDS Identification Card, the ID Number is the same as your License Number.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Verify that your phone number and e-mail are correct!(Required)

I understand I will receive a phone call or e-mail to set my appointment time & have verified my phone number is correct.

License/Photo ID Upload

Attach a copy of your photo ID below or e-mail it directly to [email protected]. You can scan in your ID or take a clear photo with your smartphone camera.

Max. file size: 50 MB.

Who referred you to this program? Please enter referring court, probation office, attorney, etc.(Required)

Product Name

Price:

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

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