Commitment to Hope Mental Health Counseling Center
Patient Eligibility Form
Patient Payment Form
Patient Payment Form
CTHC – Pay Online
Patient Name
*
First
Last
Patient DOB
*
MM slash DD slash YYYY
Email to send payment receipt
*
Select Clinician
*
Amelia Oswalt
Breanna Burge
Chavia Pittman
Darren Cooper
Justine Chappell
Kayleigh Willeroy
Murlissa Lewis
Regina Gullette
Stacy Gibbs
Bill Total
*
Service Charge
Price:
$0.00
Payment Information
Credit Card
*
I acknowledge that a 3% service fee has been added to my online payment.
Payment Total
$0.00