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 *
Last Name *
Preferred name or nickname
Parent/Guardian #1 Name *
Parent/Guardian #1 - Primary phone number: *
Parent/Guardian #2 Name
Parent/Guardian #2 - Primary phone number: *
Email: *
Street Address *
City *
State *
Zip *
Are you the applicant? *
Name of Person Completing this form: *
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
Secondary Health Insurance Company
What languages are spoken in the home? *
Currently lives with *
Please provide names, relationships, and ages of anyone under age 18.
Are there any legal or custody schedules? *
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