Payment Schedule Request PrefixMr.Mrs.Ms.Mx.MissDr.Prof.First Name *Middle NameLast Name *Email Address *Please describe your hardship/financial situation.What amount would you like processed prior to your initial meeting?How would you like your account balance (amount owed after initial payment) broken into equal payments and processed: *weeklymonthlyOther:What amount would you like processed weekly or monthly until the balance is paid?Begin processing account balance payments (give dates/details if you select "other"): *one week after the initial meetingone month after the initial meetingOther:If a payment schedule isn't feasible for your situation, please provide an alternate solution or request.If additional sessions are deemed valuable after your initial meeting, the payment schedule request agreed upon will be applied for those session payments also. Additional meeting payments will begin after the initial meeting is paid in full. If you wish to suggest something else, please indicate that below.Enter your full name below as your electronic signature to acknowledge the information provided is accurate and complete.Date *Month *Day *Year *Submit
