Online Payment - Saint Louis Counseling

Online Payments
Thank you for trusting Saint Louis Counseling!
You can take advantage of our convenient online credit card payment services by completing the information below.
A receipt of payment will be emailed to you at the email address provided on this form.

For questions, please contact Danielle Welch, Accounting Assistant, at 314-748-5670 or [email protected]

Thank you!

Online Payment

Client Information

First Name *

Last Name *

Today's Date *

Location of Service * Location of Service

Name of Therapist (South Staff) * Name of Therapist (South Staff)

Name of Therapist (O'Fallon Staff) * Name of Therapist (O'Fallon Staff)

Name of Therapist (Union Staff) * Name of Therapist (Union Staff)

Name of Therapist (Florissant Staff) *

Name of Therapist (West County Staff) *

Name of Therapist (Troy Staff) *

Name of Therapist (Bellefontaine Staff) *

Name of Therapist (Herculaneum Staff) *

Credit Card Holder Information

First Name *

Last Name *

Email *

Phone *

Address (that your Credit card is associated with) *

Address (that your Credit card is associated with)

City

State/Province

Zip/Postal

Payment Information

Amount Paid *

Credit Card

Online Payment System

Thank You!

Client Information

Credit Card Holder Information

Payment Information