Client Payments

Client Payments

To make payments for services you are receiving, please complete the payment form below. Please note: This is a secure form of payment, contact and billing information is only being collected for program service delivery purposes.

* Please only use this page to make electronic payments. Do not use any payment apps for client fees. If you’re unable to process a payment using this page, please contact your Case Manager or Therapist to discuss payment options.

Payment Amount*
Program Area*
I am making a payment for services in:
- Developing a Safe Environment (DOSE)
- Mental Health Counseling/Therapy
- Supervised Visitation
Service Type & Date of Service, Additional Comments*
Please note the DATE of SERVICE to which your payment is related. List the NAME of your Case Manager or Therapist and any additional comments and/or notes from them.
Client Name*
First Last
Your Name (if you are not the client)
Relationship to Client
Your Email*
Your Phone*
Billing Information*
Street Address Address Line 2 City State ZIP Code
Credit Card Information*

MasterCard
Visa
Supported Credit Cards: MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Payment Total
$0.00
Phone
This field is for validation purposes and should be left unchanged.

*Do not click “Submit Payment” more than once or refresh the page. If you receive an error message, our system is having issues sending an automated email receipts, but payment will be submitted.*