MENTAL HEALTH ASSESSMENT APPOINTMENT REQUEST

PAMS PLACE COUNSELING CENTER

MENTAL HEALTH ASSESSMENT APPOINTMENT FORM
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
Missed Appointment & Rescheduling Fee Policy*

I AGREE TO PPCC MISS APPOINTMENT POLICY AND I AGREE TO THE RESCHEDULING FEE
BOOKING APPOINTMENT*

I agree to the $45 processing fee being non-refundable.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
P.O./AGENT/LAWYER NAME*

First NameLast Name
P.O AGENT Phone Number*
Please enter a valid phone number.
P.O /AGENT Email*
example@example.com
NAME AND DATE*
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

Payment Amount $210.00

USDDescription

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

Should be Empty:

PAMS PLACE COUNSELING CENTER

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!

Payment Methods