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Sheila Burns
Alexandria Betke
Tiffany Gillette
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FORM – Payment Agreement
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FORM – Payment Agreement
FORM – Payment Agreement
2020-04-20T14:20:24-04:00
I understand I have a balance of
*
currently owed to Refreshing Waters Counseling and agree to have my card charged with the following amount
*
Each
*
Week
Month
Beginning on
*
Date Format: MM slash DD slash YYYY
First Name
*
Last Name
*
Date
*
Date Format: MM slash DD slash YYYY
Signature (Client/Parent/Guardian)
*
