The Center for Cognitive Education, LLC. Temple Office: 2027 S. 61st Street, Suite #123 Temple, Texas 76504 (Main Office – Georgetown: Ph. 512-868-9644) Website: www.theccedu.org

Cognitive Education Program (CEP) Temple Office Referral Form Revised 12-22-11

DATE OF REFERRAL:______CLIENT NAME:______

CLIENT REFERRAL SOURCE NAME/TITLE: (e.g., Probation/Parole Officer, County Attorney Office, CPS worker, etc) :______

Please circle the letter of the Cognitive Education Program that the client is being referred to. Provide the completed referral form to the client and advise them to be at the above address on the date you specified. The client must arrive on time, have the required $20 fee, and will need to present this form to the facilitator upon arrival to the Orientation.  Cognitive Education Program (CEP) Orientation Date: Friday______, Time 5:00pm. Orientation for the CEP does include: signing of contract; view of basic cognitive concepts; view of program structure; client being assigned a weekly class and purchasing of workbook. $20 is required for attendance at Orientation ($15 for orientation and $5 for manual). a.) Cognitive Education (non drug &/or /alcohol related offense or no history of substance abuse) 22 week program; $15 per weekly one hour class. b.) Cognitive Education - Substance Abuse Emphasis (drug &/or alcohol related offense; history of substance abuse; or recently received a positive urinalysis) 22 week program; $15 per weekly one hour class.

NOTE: Please e-mail the group facilitator, Robert L. Jackson, at [email protected] with the name and date client is to attend the Orientation. Confirmation of client attendance will be emailed to you. Advise client of program cost (cash and/or money order. checks are not accepted). Receipts provided upon request.

DIRECTIONS: From Belton Take Loop 363/57th Street Exit and cross over the bridge, turn left at the light. Turn right on 61 st Street. This is the street on which Lacks Furniture Store is located. Travel to the last office complex on your right and enter the parking lot. Enter the complex on your left about mid-way into the parking lot. Suite #123 is in the alcove of the building. From Loop 363 (Temple Mall area) Take the 57th street exit. Stay on access road through the traffic light. Turn right on 61st Street. This is the street on which the former Lacks Furniture Store is located. Travel to the last office complex on your right and enter the parking lot. Enter the complex on your left about mid-way into the parking lot. Suite #123 is in the alcove of the building.

Refer to our web site (www.theccedu.org) for information on additional services currently being offered by the Center for Cognitive Education. Send an email through the “Contact Us” section if you have any questions. Thank you.