Credit Card Authorization

$65 Credit Card Contribution

This is a contribution for a 50-minute session at a $65.00 suggested rate. Written permission is needed by your counselor to make a contribution here to secure the counseling date requested.

All donations are tax-deductible (See Tax Exempt Certificate). Please make sure to fill out all fields and read the form carefully. If this form is not completed or is filled out incorrectly, it will be disregarded.

If you are experiencing economic hardship, please fill out a Counseling Scholarship Request to see how we can assist you.

Personal Data

First Name *

Last Name *

Email *

Phone *

Address *

City *

State *

ZIP Code *

Session Date / Time *

Comments

I Understand & Agree With The Christian Counseling Consent Terms

Please read and consent to the Christian Counseling & Meeting Consent Terms.

I Agree With Christian Counseling Terms *

Yes

I Understand & Agree With The Refund Policy

You are entitled to a full refund if you cancel 72 hours before the appointment by clicking the cancelation link in your email confirmation.
You are entitled to a full refund if the counselor does not show up to the session after 15 minutes of your scheduled appointment and you have called their phone number and extension and contacted our support team online.
You are entitled to a refund if you have doctor-verified documentation due to a medical emergency.
For all refunds please submit a refund request form.

I Agree With Refund Policy *

Yes

Credit Card Data

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