PALLSS Application
Thank you for your interest in Positive Approaches and our PALLSS Clinic. Information provided in this application is considered health information. By completing the application, you specifically request and authorize us to include this information in related emails that we send you. For more information about our commitment to protect your privacy you may contact our HIPAA Compliance Officer: ann.sawicki@positiveapproaches.us.
The Positive Approaches: Life Lessons & Social Success (PALLSS) Clinic
Welcome!
This is an online form. It is meant to be completed during a single session. If you would like to preview or print the PALLSS Application, please use the following link:
First Name *
Your answer
Last Name *
Your answer
Preferred name or nickname
Your answer
Parent/Guardian #1 Name *
Your answer
Parent/Guardian #1 - Primary phone number: *
Your answer
Parent/Guardian #2 Name
Your answer
Parent/Guardian #2 - Primary phone number: *
Your answer
Email: *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Are you the applicant? *
Name of Person Completing this form: *
Your answer
What is your relationship to applicant? *
I attest the information below is accurate and represents a true history and current functioning of the applicant. *
Required
Do you plan to use health insurance benefits? *
Primary Health Insurance Company
Your answer
Secondary Health Insurance Company
Your answer
What languages are spoken in the home? *
Your answer
Currently lives with *
Please provide names, relationships, and ages of anyone under age 18.
Your answer
Are there any legal or custody schedules? *
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