Intake Forms

Facebooktwittergoogle_plusredditpinterestlinkedintumblrmailFacebooktwittergoogle_plusredditpinterestlinkedintumblrmail

Click here to register. You will be taken offsite to the PMA Member Registration page.

Step 2: Complete Anita’s Client Intake Form:

Please note: upon submitting this form, please email Anita directly to alert her to your form submission: anitabains@verizon.net



  •   Yes
      No
      Gained
      Lost

  •   Yes
      No
  •   Yes
      No
  •   Yes
      No



  •   Yes
      No
  •   Yes
      No
  •   Yes
      No
  •   Yes
      No
  •   Yes
      No
  •   Yes
      No
  •   Yes
      No
  •   Yes
      No



  • By clicking "Yes" below, I hereby give Anita Bains permission to call my emergency contact #1, and if not available #2, if she and/or I deems it appropriate when extra support is needed and/or in case of an emergency.
Facebooktwittergoogle_plusredditpinterestlinkedintumblrmailFacebooktwittergoogle_plusredditpinterestlinkedintumblrmail