LIMA_Service Payment

Service Payment
Your Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email for receipt*
example@example.com
Payment for/Client's name(s)*
Date of Counseling Session being paid for

MonthDayYear
Date
Date of Counseling Session being paid for

MonthDayYear
Date
Details/Notes (if applicable)
Enter Payment Amount

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USDHalf Hour Counseling = $42.50 | Hour Counseling = $85 | Intake Marriage Appointment = $130 | Marriage SYMBIS Assessment = $30

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.