Catholic Charities Bloomington

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Catholic Charities Bloomington continues to offer telehealth therapy to clients. We strive to provide the same quality and level of service as in the office.

We are now accepting online payments here. If you have any questions or need assistance please contact Rachael Vickrey at rvickrey@ccbin.org

Description

Amount

Total

Service Fees

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Client Name: *

Therapist:

Statement Number:

Your Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Telephone: *

E-mail: *

A receipt will be e-mailed to this address.

Newsletter:

Check here to receive newsletter and e-newsletters.

Is any of your contact information new or need to be updated? *

Your Payment Information

Name on Card: *

Card Number: *

Security Code: *

Expiration Date: *

Name on Account: *

Routing Number: *

Account Number: *