Healing The Heart (May 15th-22nd, 2022)
Please fill out this form and click submit.
Name
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Phone
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Address
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Payment
Payment in Full ($175.00)
Deposit ($100)
Remainder After Deposit ($75)
Payment in Full ($175.00)
Deposit ($100)
Remainder After Deposit ($75)
Amount
If Filling out this form, or paying for another person, Please list your name here.
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Are you at least 18 years old?
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Do you attend church, if so, which one?
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Are you currently in counseling? If so, please get permission from your therapist.
*
Are you able and willing to commit to be at all the sessions?
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Please select one option.
Yes
Credit/Debit Card Number
Expiration Date/CVC
Name on Card
Card Billing Address
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AR
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AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
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YT
Submit
Description
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