Payment Schedule Request
If you are experiencing financial hardship, you are welcome to request a payment schedule below.  If you need an alternate solution, you can request that below as well.  Your request must be approved before our session.  

Submitting this form gives me (Denise Kirsop) permission to process the payments as you have outlined. If you wish to revise a payment schedule, simply contact me with the details.  

This form is created with Google Forms. I have a BAA signed with Google for HIPPA purposes.  If you prefer a different format please let me know:
admin@denisekirsop.com or 407-948-9262 (phone/text)

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Email *
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) be broken into equal payments and processed: *
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"): *
If a payment plan isn't feasible for your situation, please provide an alternate solution or request.
If additional sessions are deemed valuable after your initial session, the payment solution/request agreed upon will be applied for those session payments also.  Additional session payments will begin after the initial session 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 *
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