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RISTIAN COUNSELING

JC CHRISTIAN

COUNSELING1iÂť

1821 Oregon Pike, Suite 212, Lancaster, PA 17601 Phone: (717) 278-8326, FAX: 1-866-285-7198

On-Line Termination of Services and Refund Form

I,

am terminating services for

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as of

------

due to

_

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I am also requesting to be refunded the money that is owed to me (if any) according to the Counseling Policy.

Client Name: ----------------------------------------------Client Signature:

Responsible Party:

Witness:

-------------------------------------

_

_


Online Refund Request Form