Register

Registration is only required if you do not have a username. Please check your spam & junk mail folders to ensure you have not already received an email with a username and password. If you already have a username log in here

Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

Client Information

/ Middle Initial

( optional )
 

( MM-DD-YYYY )






( for Text Message Reminders )

Bill To Contact

/ Middle Initial







Emergency Contact

First Name
Last Name
Phone
Mobile
Relation
Email
Street Address
City
State
ZIP Code

Log in Details

( If client is a minor, the legal guardian must enter their email address below. )



Between 8 and 40 letters and numbers

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )




( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

No-Show/Late Cancellation Policy


If you must cancel an appointment, Paul A. Baillif, MS, LPC, LLC requires that you do so no less than 24 hours in advanceof your scheduled appointment time.  If you do not give appropriate notification or do not show up for an appointment you will be assessed a $25 no-show fee.  Please note that this no-show fee cannot be submitted to the insurance company for reimbursement and is the sole responsibility of the client.



Failure to pay for services rendered is considered a breach of therapeutic contract which may result in termination of service.

( Type Full Name )
( Full Name )