A $20.00 fee will be charged for every missed appointment where a cancellation, or request for rescheduling, has not been received by the program with at least 24 hours’ notice.
First Name: (Required)
Last Name: (Required)
Date of Birth: (Required)
Phone Number: (Required)
E-mail: (Required)
Driver's License No: (Required)
Desired Location:
Desired Service: (Required)
Desired Week: (Required)
Desired Time: (Required)
How did you hear about the program? (Required)
Notes: (Provide any additional Case information here)