Referral Form – DUI/DWI Classes

Instructions

Alcohol Education or DUI/DWI classes are designed for those who may have an issue with using alcohol which has lead to an arrest or charge of “driving under the influence” and/or” driving while intoxicated”.

Please fill in all the form fields as accurately as possible. If there is missing or incomplete information, it may cause a delay in processing your referral information.

You have two options to submit a referral to us.

  • It can be printed, completed and faxed to 410-220-0730.  ATTN: Ms. Wise

Click Here to Print

  • Fill in the form to the right and submit it through our secure website

For questions about completing this form or inquiries about our services please call 410-617-8026  x 0 or email essentialinfo@ebhsinc.com and a program representative will reply within 1 business day.







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