Contact Information

First Name

Last Name

Email

Phone

Payment Purpose/Invoice

Payment Information

Please select a service

$5.00 - Single Session Therapy (SST)

$5.00 - Individual Counseling (IC)

$10.00 - Couples Counseling (CC)

$25.00 - No Show or Late Cancel/Reschedule for IC, CC, and SST

$25.00 - Summer IC, CC, and SST (when enrolled in Fall not Summer)

Career Fair Registration includes two representatives. Price for additional representatives is $30 per person.

Price

Quantity

Total

.00

Grand Total