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Our Staff
Chris Bassett, LMFT
Kathy Estep, LPCC
Maggie Kelleher
Ramona McGonagil, LPCC
Micah Strouse
Jen Hahn, LPC
Bob Weinkauf, MA
Our Services
Individual Counseling
Relationship Counseling
Child & Family Counseling
Reunification Therapy
About Us
Session Fees
COVID Considerations
Forms
Financial Policies and Authorization
Consent for Release of Information
Collateral Contact Form
Community Sponsorship Agreement
3rd Party Recurring Payment Authorization
Submit a document
blog
Contact Us
Home
Our Staff
Chris Bassett, LMFT
Kathy Estep, LPCC
Maggie Kelleher
Ramona McGonagil, LPCC
Micah Strouse
Jen Hahn, LPC
Bob Weinkauf, MA
Our Services
Individual Counseling
Relationship Counseling
Child & Family Counseling
Reunification Therapy
About Us
Session Fees
COVID Considerations
Forms
Financial Policies and Authorization
Consent for Release of Information
Collateral Contact Form
Community Sponsorship Agreement
3rd Party Recurring Payment Authorization
Submit a document
blog
Contact Us
3rd Party Recurring Payment Authorization
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3rd Party Recurring Payment Authorization
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
*
MM slash DD slash YYYY
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
*
Credit/Debit/Other Card
Check (only an option for Churches)
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
Zip Code
Would you like to receive our email newsletter we send 1-2 times a month?
Yes
No
Thank you for caring and supporting this person.
If we need anything else, Ann will reach out to you. Otherwise, you are done!
Email
This field is for validation purposes and should be left unchanged.
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