ASI FOR DRIVER LICENSE APPOINTMENT REQUEST

PAM'S PLACE COUNSELING CENTER

STATE OF MICHIGAN ASI FOR DRIVER'S LICENSE
Missed Appointment & Rescheduling Fee Policy

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 full schedules, so please ensure you are available at the time you select for your assessment.

You can expect a follow-up email or phone call from your therapist. It is important to be available at your scheduled appointment time.

If you miss your appointment without prior notice (no call/no show), a $65 rescheduling fee will apply.

For any changes to your schedule, please contact us as early as possible.

Thank you,
Mr. Edgar

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POLICY FOR MISSED APPOINTMENT & RESCHEDULING FEE AGREEMENT*

I AGREE that missing two appointments WILL FORFEIT MY PAYMENTI AGREE TO THE $65 RESCHEDULING FEE FOR MISSING MY APPOINTMENT WITHOUT CALLING TO RESCHEDULEI agree to the $45 processing fee being non-refundable.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
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!*
EMAIL ADDRESS
Date 1*

MonthDayYear
Date
Hour MinutesAM/PM Option
Date 2*

MonthDayYear
Date
Hour MinutesAM/PM Option
Date 3*

MonthDayYear
Date
Hour MinutesAM/PM Option
P.O./AGENT Name

LAST NameP.O /AGENT EMAIL
WHY DO YOU NEED AN ASI?
ASI Services & Fees

1-Hour ASI Service – $255
This service includes completion of your portion of the ASI, along with the therapist completing their required portion.

2-Hour ASI Service – $310

The first hour is dedicated to completing the assessment.
The second hour includes assistance with completing the State of Michigan ASI form, reviewing the form with you, and helping you fully complete all required sections.
If you have any questions regarding these services or fees, please contact our office.

Thank you for your understanding and cooperation.

Sincerely,
Mr. Edgar

Payment Amount*

USDASI FOR DRIVER LICEINSE FEE $210.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

Email
example@example.com
Should be Empty:

PAM'S PLACE COUNSELING CENTER

Payment Methods