First Name

Last Name

Email *

Phone *

Which industry are you employed in, or seeking employment in? *

Is DISA involved in your case? *

I agree to receive SMS messages from American River Wellness regarding my case, appointments, and service updates. Message & data rates may apply. Message frequency may vary. Reply STOP to opt-out or HELP for help.

Agree

SAP AGREEMENT

I AGREE to the SAP Informed Consent, Authorization to Disclose, and Service Terms listed above.

If CDL Driver/Student, FMCSA clearinghouse request may be required

I AGREE *

I AGREE not to be in a moving vehicle at the time of the appointment either driving or as a passenger. By agreeing to this I understand that my appointment will be cancelled if in a moving vehicle.