Group Therapy/Class Financial Form

Payment method for group therapy or classes

Today's Date*
MM slash DD slash YYYY
Your Name*
First Last
Phone Number*
Which group therapy or class are you attending?
You can write something like: "Premarital Feb 2023" or " "teen girls group"
Consent*
I agree to the payment policy
PAYMENTS/CANCELLATIONS:
I understand that the fee for my group therapy or class is for the number of sessions specified in the advertisement. The full fee is required before the first session and will be charged even if I cannot make it to all sessions.
Recurring Payment Authorization*
I authorize LIGHTHOUSE CHRISTIAN COUNSELING to charge my card for the group therapy/class fee through the method I indicate below.
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.
Name on Card*
Card Number*
Expiration Date*
CVV*
Address Associated With This Card*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
If another party is paying for a portion of your sessions, write the name of who is paying for the session, their contact information, and the payment agreement (50%, $100...).If the other party is paying 100% of you fee, please call the office at (970) 413-8998.
Would you like to receive our email newsletter we send 1-2 times a month?*
Name
This field is for validation purposes and should be left unchanged.