Skip to content
734-794-3777
|
info@refreshing-waters.com
Facebook
LinkedIn
Twitter
Instagram
Search for:
Menu
Home
About Us
Our Team
Sheila Burns
Amber Cunnings
Taryn Konevich
Our Services
ADHD
Alpha-Stim
Anger Management
Anxiety & Stress
Auricular/Ear Acupuncture
Career Counseling
Children/Teens
Christian Counseling
DBT
Depression
EFT
EMDR
Gender/Identity LGBT
Genetic Testing
Grief and Loss
Life Coach
Pre-Marital Counseling
Relationship Counseling
Substance Use/Addictions
Therapy
Trauma
Resources
Patient Reviews
Rates/Insurance
Patient Portal
Employment Opportunities
Ann Arbor Medical Community
Contact Us
FORM – Payment Agreement
Home
/
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)
*
Go to Top
