Pam's Place Counseling Center

How are you attending your classes? Please check only one box.*

IN PERSONONLINEZOOM CLASSES ONLY

If you are not attending 13 class, how many classes will you need to attend?

Signature*

NAME AND DATE*

MEDICAL HISTORY (MEDICATION, DIAGNOSIS OR TREATMENT)*

Take Photo*

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

P.O. /AGENT Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

AGENT NAME/P.O.*

AGENT Phone Number*

Please enter a valid phone number.

AGENT Email*

example@example.com

No Refund Policy

Dear Online Student,

Thank you for choosing to take your classes via Zoom or online. While we also offer in-person classes, please note that we cannot be held responsible for issues that may arise with online courses, including but not limited to:

The class dropping, unless the issue is on our end
Enrolling in the wrong class
Not receiving the online link

If any of these issues occur, you will be responsible for reordering or re-enrolling in another class.

If you disagree with this policy, we kindly encourage you to consider switching to in-person classes instead.

Thank you for your understanding and cooperation.

Best regards,
Mr. Edgar

Financial Policy Acknowledgment Form

This document serves as formal acknowledgment of Pam’s Place Counseling Center’s financial and program policies regarding disputed charges.

I understand and acknowledge the following:

Once services are rendered by Pam’s Place Counseling Center, all fees are considered earned and non-refundable.
Disputing or attempting to reverse charges after services have been provided is a violation of program and financial policies.
I further acknowledge and agree that if I dispute any charges after receiving services:

The Court, presiding Judge, Probation Officer, and/or Parole Officer will be notified.
Any Certificate of Completion and/or Letter of Completion issued will be deemed null and void.
I will be terminated from the program immediately.
I will be permanently ineligible to re-enroll or receive future services from Pam’s Place Counseling Center.
Pam’s Place Counseling Center may pursue further action as permitted by law, including legal remedies (prosecutions) and collections.
I understand that:

This signed acknowledgment will be maintained in my official file.
This document may be relied upon in court or by supervising agencies if necessary.
By signing below, I confirm that I have read, understand, and agree to the terms outlined above.

I AGREE TO THE FINANCIAL POLICY ACKNOWLEDGEMENT & NO REFUND POLICY

Signature*

NAME AND DATE*

Payment Amount $35*

USDIntake Fee

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

I have read this contract in its entirety.
I understand and agree to all of the terms and conditions outlined in this agreement.
I understand that there are no refunds for duplicated classes.
I understand that before purchasing a class, I am responsible for verifying that it is the correct program and class required.
I understand that I may contact Pam’s Place during normal business hours by phone or email if I need assistance prior to completing any transaction.

First NameLast Name

Name*