Payment Agreement and Session Confirmation Form

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Please complete this form to confirm your Christian counseling session or coaching package. Payment is required before services begin.

Full Name *

Email *

Phone Number *

Which service are you booking today? *

Individual counseling session (50 minutes, $55 per session)

Monthly trauma-informed email coaching (weekly guidance and encouragement, $45 per month)

How are you submitting payment? *

Paypal

Venmo

Paypal or Venmo user name *

Amount sent *

Payment Agreement:

Please check each one to acknowledge

I understand that payment is due prior to my session or coaching start

I understand that if I cancel without notice, the session or month cannot be refunded but can be rescheduled within 30 days

I agree to the rates listed for the selected service

Required

By typing my name below, I confirm that I understand and agree to the payment terms *

Date *

YYYY

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