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
*
Anthony Saracina
April Waterford
Arnisha Rogers
Cerina Woodall
Jay Shultz
Kristv Kuhn
Melissa Baker
Murlissa Lewis
Sierra Mayle
Vicky Byers Ward
Regina Gullette
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