DUI Program – Leave of Absence (LOA) Request

You may submit this form to request a Leave of Absence (LOA) for the following reasons:

  • Travel for work
  • Military duties
  • Illness or family illness
  • Incarceration including home arrest (the $25.00 fee is waived for incarceration LOAs)
  • Extreme personal hardship or family emergency

You must submit the request for the LOA at least 24 hours in advance of the leave. You must submit documentation proving the reason for the request.

Submitting this form does not automatically result in approval for your leave of absence. You will receive an email or call from our office confirming the LOA once approved.

The fee for a Leave of Absence is $25.00. All activities missed while on an LOA must be made up at the end of your program. You must continue to make any scheduled program payments while on an LOA.

If you are unable to attach proof to this request, you may fax, mail, email, or bring the proof to our office prior to the commencement of the LOA. If we do not receive proof we will not be able to approve the LOA.

Section 1: Client Information
Section 2: Program Location
You may select more than one reason.
Section 3: Other reason for Leave of Absence request.
If applicable, you may upload your documentation here:
Section 4: Credit Card and Payment Information
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