WPA


WEEKLY PAYMENT AGREEMENT

 

Name:

Session Fee:                   

Weekly Payment Towards Balance: 

Our Heart

The counselors of Cornerstone Christian Counseling desire that all persons who genuinely want help are able to receive it, regardless of their financial circumstances. It’s out of this desire our counselors agree to accept a payment plan for their services, in qualifying situations, over time instead of at the time of service. We do so without charging any interest and with no maximum repayment term. We want you to be able to get the help you need.

Repayment Arrangement

  • I understand that my counselor has agreed to accept payment for his or her services over time to allow me to get the help I am requesting in spite of my financial circumstances.

 

  • I understand that my session fee of    plus any other fees I incur for services, resources, or late cancellation will be charged to my account.

 

  • I understand I will incur a debt to Cornerstone Christian Counseling which I agree to repay in weekly installments of  until my account balance is satisfied.

 

  • I understand if my balance is satisfied but I am continuing to schedule appointments I may accumulate a positive balance on my account to be used for future sessions. Any positive balance remaining at the end of my counseling will be returned to me by check.

I wish to use the credit or debit card I have placed on file ending in for making my weekly recurring payments for services and products received from MyCounselor until my account is paid and settled. 

I understand that if I default on this agreement the billing information I have provided to Cornerstone Christian Counseling will be submitted to Wakefield & Associates for collections of my debt. 

By signing below I testify that I have read and understand the above financial policies and do hereby agree to fulfill my financial obligations as so stated.  

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Cornerstone Christian Counseling https://www.christiancounselingco.com
Signature Certificate
Document name: WPA
Unique Document ID: 8e54209d9fd9235e1040e06da8d83416d6230a03
Timestamp Audit
April 11, 2019 4:12 pm MDTWPA Uploaded by Angie Taylor - info@christiancounselingco.com IP 24.9.253.246