Cornerstone of Hope · Lima/Bluffton

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Client Name (If different from above)

First Name

Last Name

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Service Payment Information

Service Payment

*

$40 - Half-Hour Session

$80 - Hour Session

$120 - Marriage Intake Assessment

$30 - Marriage SYMBIS Assessment

$

Date of Appointment Being Paid For (If applicable)

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Date of Appointment Being Paid For (If applicable)

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Date of Appointment Being Paid For (If applicable)

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PLEASE NOTE:

You will be directed to a PayPal payment service. You do not have to use a PayPal card or have an account. You may use any debit/credit card payment you would like.

Lima/Bluffton_Service Payment

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