Counseling Payment

Client Name (Each payment can only be linked to one person. If you're paying for multiple people, please submit a separate payment for each person.)(Required)

First Last

Client Email(Required)

Client Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Session date(s)(Required)

If this payment covers multiple sessions, list each date (e.g., 6/2, 6/9, 6/16).

Payment Type(Required)

Individual Therapy
Group Therapy
Training/Workshops

Individual Counselors(Required)

Mary Cullman
Deborah Anne King
Karen LaGotta
Emily Laitmon
Tracy Turner
Marianne Walsh
Matt Huffman
Sarah Lieberman
Lorraine Kransdorf

Payment Amount. Please make sure your total payment matches the number of sessions listed. If the preset amounts don't add up correctly, select 'Other' and enter the correct total.(Required)

$75
Other

Other Amount(Required)

Group(Required)

Support After Suicide
Maggie Rose Group
Spouse/Partner Loss Group
Child Loss Group
Parent/Sibling Loss Group

Payment Amount (Group) Please make sure your total payment matches the number of sessions listed. If the preset amounts don't add up correctly, select 'Other' and enter the correct total.(Required)

$25
Other

Other Amount(Required)

Training/Workshop Name(Required)

Payment Amount(Required)

Total

$0.00

Billing Information(Required)

Is your billing address the same as the client receiving services?

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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Complete one form per person to pay for BCW Tree House counseling services.