2026 Education Program Online Registration

Program you wish to attend:*

SATURDAY, 8:00 AM – 5:00 PM

Thank you for choosing the Education Program at Lake-Geauga Recovery Centers, Inc. This program was designed to give participants an overview of substance abuse and addiction, and to provide valuable information in maintaining healthy lifestyle choices.

To be FULLY registered, payment must be included with this registration form. Registration deadline is 48 hours before the day of the program, or when the program is full. Please call to check on program status.
The registration fee is $125.00.
You may send cashier’s check or money order (payable to Lake-Geauga Recovery Centers) with registration form to the:
Lake-Geauga Recovery Centers, Attn: Anger Management Intervention Program
9083 Mentor Avenue,
Mentor, Ohio 44060
Or credit card in person at any of our outpatient offices (9083 Mentor Ave, Mentor; 134 S. St. Clair, Painesville; 209 Center St., Chardon) from 9:00 AM – 4:00 PM Monday through Thursday and 9:00 AM – 3:00 PM Friday. Please call in advance to check for holidays or office closings.
No cash or personal checks will be accepted.
Upon receipt of your registration and fee, a confirmation letter containing program date, instructions and guidelines will be mailed to you. At this time, your information maintained by this program is protected by federal laws and regulations as per the Confidentiality/Privacy Rule below.
If you do not receive a confirmation letter, it is your responsibility to notify Lake-Geauga Recovery Centers. Call 440-255-0678 if you have any questions.
Your registration fee is non-refundable after scheduling. If you do not attend, you will forfeit your fee. A rescheduling fee of $15.00 will be required before being accepted into another program date.

Name:*

First Last

Address:*

Street Address Address Line 2 City State ZIP Code

Home Phone:*

Work Phone:

Email Address:*

Date of Birth:*

Gender:*

Male

Female

Referral Source:*

Association:*

Address:*

Street Address Address Line 2 City State ZIP Code

Employer:*

if this information is not available please enter Unknown

Address:*

Street Address Address Line 2 City State ZIP Code

Do You Need to Comply With Regulations of the Department of Transportation?*

Yes

Emergency Contact Name:*

First Last

Relationship:*

Phone:*

Address:*

Street Address Address Line 2 City State ZIP Code

Race:*

Ethnicity:*

Puerto Rican

Mexican

Cuban

Not Hispanic or Latino

Other

Language:*

English

Other

Marital Status:*

Divorced

Married

Single

Widowed

Current Living Status:*

Own Home

Friend or Relative's Home

Supervised Group Living

Other

Education Level: (0 thru 19):*

Please enter a number from 0 to 19.

Veteran:*

Yes

Religion:*

CONFIDENTIALITY/PRIVACY RULE

I understand that my records are protected by federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. Drug abuse patient records are also protected under the Health Insurance Portability Act of 1996 (HIPAA), 45 C.F.R., parts 160 and 164. The HIPAA Privacy rule provides individuals the right to request confidential communications or that a communication of PHI is made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home. The Privacy rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and request for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by an individual.

Contact Number:*

For registration information in the event we need to check information on the registration form.

Education Program:

Price:

I, The Undersigned, Have Read, Understand and Agree to Abide by the Above Rules and Certify That All Information Contained in this Form is True and Accurate:*

Yes

2026 Education Program Online Registration

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