Counseling Programs Payment Form

Counseling Programs Payment Form
Who are you paying for?*

I am paying for myselfI am paying for myself and spouseI am paying on behalf of someone else
Applicant/Student Name

First NameLast Name
Applicant/Student Name 2

First NameLast Name
Payor Name*
Full Name / Organization Name
Program Payment Type*
Our policy requires that an Induction Fee payment be made only after an individual has been accepted into the Residential Program. Please confirm that you or the person you are paying for has been accepted into the Residential Program before proceeding with payment.

Yes, I have been accepted into the Residential ProgramYes, the person I am paying for has been accepted into the Residential Program
What is your payment for?

Full PaymentPartial Payment

Payment Amount*

USDEnter Amount

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Payment Agreement

Yes, I understand that all program payments are non-refundable.
Should be Empty: