Cornerstone of Hope · Lima/Bluffton

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Lima/Bluffton_Service Payment

Contact Information

Your Name

First Name

Last Name

Client Name (If different from above)

First Name

Last Name

Your Phone

Your Email

Verify Email

Your Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

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)

(mm/dd/yyyy)

Date of Appointment Being Paid For (If applicable)

(mm/dd/yyyy)

Date of Appointment Being Paid For (If applicable)

(mm/dd/yyyy)

Details/Notes (If applicable)

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.