Family Paths Client Payment Form

PAYMENT FORM

If you would like to make payments for services, you can do so using this form. You will need a credit card or a debit card with a Visa or Mastercard logo on it.
In order to complete this form, you will need:

Your credit card number
The name of your therapist or parent education instructor
The dates of service you are paying for (therapy session dates, Finding Peace Within session dates, or Parent Education class dates & teacher)
The amount of your agreed upon fee per session

If you have any questions about your fee, please contact your therapist or PE instructor.

Full Name of Payer*

First NameLast Name

Name of Client, if not yourself.

First NameLast Name

Which service are you submitting a payment for?*

Which Parent Education session are you paying for? If you are a therapy client, choose Does not Apply.*

If paying for therapy, who is your therapist? If you are a PE client, choose Does not Apply.*

If paying for therapy, which dates of service are you paying for? If you are a PE client, type N/A.*

What is your fee per session, as agreed upon by your therapist, PE instructor or group leader?*

My Payment*

USDEnter Amount

Credit/Debit Card Payment

E-mail*

Phone Number*

Area CodePhone Number

Message