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. 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 offer up to a 6 month 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 that there is a credit limit of $500, and if I have reached the limit sessions cannot be attended or scheduled until my balance falls below the $500 credit limit.

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 Cornerstone Christian Counseling 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 Rocket Receivables 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: c95d3de0a2eff189c2333409debd535074f846c3
Timestamp Audit
April 11, 2019 4:12 pm MDTWPA Uploaded by Angie Taylor - info@christiancounselingco.com IP 174.24.96.169