CLIENT COUNSELING INTAKE PACKAGE

PAMS PLACE COUNSELING CENTER

CLIENT INTAKE PACKAGE
Thank you for choosing Pam's Place Counseling Center for your counseling needs.
BY CHECKING THE BOXES BELOW YOU AGREE TO THE CONTRACTS ABOVE THAT YOU JUST READ.
Terms and Conditions
What Brings You In Today?
MEDICAL HISTORY (MEDICATION, DIAGNOSIS, AND TREATMENTS)
CLIENT Signature
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.Format: (000) 000-0000.
Probation Officer / Referral Source Information

First NameLast Name
Probation Officer / Referral Source Information (If this is for you, just put your email)
example@example.com
P.O. AGENT Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
CLIENT NAME AND DATE
CLIENT Signature
POLICY FOR MISSED APPOINTMENTS & RESCHEDULING FEE:
Please be advised that missing two appointments will result in the forfeiture of your 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 immediately.
Thank you,
Mr. Edgar
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 $165.00.
Any additional session after the first session will be $145.00.

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.

Best regards,
Mr. Edgar

Payment Amount $165.00

USDcounseling

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

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PAMS PLACE COUNSELING CENTER

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

Payment Amount $165.00*

Payment Methods

Payment Amount $165.00