CLIENT INTAKE PACKAGE

PAMS PLACE COUNSELING CENTER

CLIENT INTAKE PACKAGE
BY CHECKING THE BOXES BELOW YOU AGREE TO THE CONTRACTS ABOVE THAT YOU JUST READ.
What Brings You In Today?
MEDICAL HISTORY (MEDICATION, DIAGNOSIS, AND TREATMENTS)*
CLIENT Signature*

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CLIENT NAME DATE*
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CLIENT Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
P.O. AGENT Name*

First NameLast Name
P.O./AGENT Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
P.O. AGENT Email*
example@example.com
P.O. AGENT Phone Number*
Please enter a valid phone number.
CLIENT NAME AND DATE*
CLIENT Signature*

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POLICY FOR MISSED APPOINTMENTS & RESCHEDULING FEE:
Please be advised that missing two appointments will result in the forfeiture of your assessment fee. There are no exceptions to this policy. Our therapists have very busy schedules, so kindly ensure you are available when scheduling your assessment AND/OR counseling sessions.
EXPECT AN ADDITIONAL EMAIL OR CONTACT VIA PHONE OR EMAIL FROM THE THERAPIST.
Please be available at the appointment time. There will be an additional
$65. fee to reschedule for a no call/no show. Please contact us for any changes in your schedule.
Thank you,
Mr. Edgar
I AGREE TO THE POLICY FOR MISSED APPOINTMENT & RESCHEDULING FEE
Please provide three available dates and times below for your appointment, starting at least three days from today. You will receive an email or phone call confirming your appointment. Thank you!
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
FIRST COUNSELING SESSION

The total amount due for your first counseling session is $160.00.
Any additional session after the first will be $100.00.

Once you have completed your payment, we will confirm your appointment.

If you have any questions or need assistance, please don’t hesitate to contact us.

Payment Amount: $160.00

Best regards,
Mr. Edgar

Payment Amount $160.00*

USDcounseling

Payment Methods

Credit Card

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PAMS PLACE COUNSELING CENTER

BY CHECKING THE BOXES BELOW YOU AGREE TO THE CONTRACTS ABOVE THAT YOU JUST READ.

Payment Methods