3rd Party Recurring Payment Authorization

Client Name*

First Last

Name of Party Contributing to Fees*

First Last

Phone

Email

Lighthouse Christian Counseling Community Sponsorship Agreement*

I understand and agree that I am financially responsible for the fees incurred through the clients services at Lighthouse Christian Counseling.

It is our mission at Lighthouse Christian Counseling to provide the opportunity for affordable mental health care. It has been our passion to come alongside individuals, couples, and families to provide counseling and prayer through the love and hope that only God can provide.

This agreement below indicates that a sponsor will be financially responsible for the fees incurred through the clients services at Lighthouse Christian Counseling.

What portion of the fees incurred at Lighthouse Christian Counseling are you willing to pay?*

100%

This agreement is in effect until:*

You can define this in a number of ways: 1) # of sessions 2) Amount of money 3) Period of time 4) A certain event occurs 5) NA: The agreement will continue indefinitely

Today's Date*

Payment Method.

Consent*

I authorize LIGHTHOUSE CHRISTIAN COUNSELING to charge my sessions through the method I indicate below.

We accept checks and credit cards (VISA, MasterCard, Discover, and American Express).

Recurring Payment Choice*

If choosing cash or check, we will still need a card on file in case of late cancellations, no-shows, or lack of payment. Thank you.

Type of Card

Visa
MasterCard
Discover

Name on Card

Card Number

Expiration Date

CVC

Address associated with the card.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Would you like to receive our email newsletter we send 1-2 times a month?

Thank you for caring and supporting this person.

If we need anything else, Ann will reach out to you. Otherwise, you are done!

Phone

This field is for validation purposes and should be left unchanged.