ASI FOR (CDLs )APPOINTMENT REQUEST

PAM'S PLACE COUNSELING CENTER

SAP CDL Intake
Good day. This intake form will be sent to our therapist for a drug and alcohol assessment to determine whether treatment is needed and, if so, what type of treatment—either inpatient or outpatient.

If your concern is not drug- or alcohol-related, this may not be the correct form for you. If you are unsure, please contact our office for guidance. Please note that the $65 intake processing fee is non-refundable.

Please complete the information below and submit your payment. Once completed, you will be scheduled with our SAP provider.
Name*

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
AGENT Name

LAST NameP.O /AGENT EMAIL
Explain your situation in brief details?
After your intake form has been completed, our team will review your information and, we will forward your information to SAP for next steps. Please allow us a brief time to process your intake. If your information is forwarded, a representative from SAP will reach out to you soon.

Thank you an have a great day,

Pam's Place

65*

USDDescription

Credit Card

Apple Pay

Google Pay

Cash App Pay

PAM'S PLACE COUNSELING CENTER