Family Law SmartMobile Enrollment Form

"* (required)" indicates required fields

Client Information

First Name* (required)

Last Name* (required)

Cellphone* (required)

Zip Code* (required)

Email* (required)

State

City

Street Address

Date of Birth

Program Start Date

The client is required to pick up their device and begin the program by:

Are you currently, or have you ever been, a client of Smart Start?

How did you hear about Smart Start?

Referral Name (if applicable)

Customized Test Windows

Use the fields below to set up a schedule that's specifically tailored for your client, with Scheduled or Random testing. You can specify up to 10 tests each day by clicking on the plus symbol on each line.

Default test windows will be set for 6AM to 8 AM, 12PM to 2PM, 5PM to 7PM, and 9PM to 11PM. To customize the testing windows please send an email to [email protected] with your client information and preferred test windows.

Sunday

SUNDAY

Start

End

Timing

Monday

MONDAY

Start

End

Timing

Tuesday

TUESDAY

Start

End

Timing

Wednesday

WEDNESDAY

Start

End

Timing

Thursday

THURSDAY

Start

End

Timing

Friday

FRIDAY

Start

End

Timing

Saturday

SATURDAY

Start

End

Timing

Reporting Notifications

Choose up to four recipients to receive reports via email.

Choose up to four recipients to receive reports via email. A third-party release form must be completed for each recipient and submitted to [email protected].

Monitoring Contacts

Name *

Address

Email *

Phone Number