Family Law SmartMobile Enrollment Form

"* (required)" indicates required fields

Client Information

Client Name* (required)

Date of Birth* (required)

Street Address* (required)

State* (required)

City* (required)

Zip Code* (required)

Phone Number* (required)

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?* (required)

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.

PLEASE NOTE: If you choose not to customize testing, test windows will automatically be scheduled for 6 a.m. to 8 a.m.; Noon to 2 p.m.; 5 p.m. to 7 p.m.; 9 p.m. to 11 p.m.

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.

PLEASE NOTE: A release document will be required for each report recipient. We will send you the appropriate forms as needed.

If you are enrolled or are an attorney/court representing a client in the Family Law Program, and need to make changes to your account, please email familylaw@smartstartinc.com.

Monitoring Contacts

Name *

Address

Email *

Phone Number

Name

This field is for validation purposes and should be left unchanged.

(800) 831-3299

Family Law SmartMobile Enrollment Form

Client Information

Customized Test Windows

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

Reporting Notifications

Solutions

Locations

Support

Company Information

Contact Information

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