PAMS PLACE COUNSELING CENTER
COMPREHENSIVE PARENTING INTAKE PACKAGE
BY CHECKING THE BOXS BELOW YOU AGREE TO THE CONTRACTS ABOVE
Signature
TYPE IN NAME AND DATE
Take Photo OF STATE ID OR DRIVER LICENSE
MEDICAL HISTORY (MEDCATION, DIAGNOSIS, AND TREATMENTS)
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
AGENT NAME
First Name
Last Name
AGENT Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
AGENT Email
example@example.com
AGENT Phone Number
Please enter a valid phone number.
Signature
NAME AND DATE
https://www.govpaynow.com/gps/user/plc/a001mg
ASI Payment Link HIGHLIGHT. THEN CLICK ON GO GO TO. -TO MAKE PAYMENT
Submit
Should be Empty: