Intake Payment Form
Thank you for choosing Anger Management 818!
Client's First Name:
Client's Last Name:
Client Phone Number:
Please enter your email address below:
Please confirm your email address:
Select the location you will be attending:
Telehealth - via Zoom
Please choose the item you would like to pay for:
Anger Assessment (Part 1 of Intake) ($70)
(Offered at limited locations only) Intake and Individual Session 1 with Certified Anger Management Counselor ($100)
Intake and Individual Session 1 with Licensed ($200)
Intake and Individual Session 1 with the Director of Anger Management 818 ($300)
Returning customer code:
Even if you do not have a PayPal account, click the "Checkout With PayPal" option on the payment screen and the follow directions given for "Don't have a PayPal account".
*********READ THE FOLLOWING INSTRUCTIONS BEFORE SUBMITTING PAYMENT*********
After submitting your intake payment on the PayPal payment system using a credit or debit card, click the
"RETURN TO MERCHANT WEBSITE"
button. After clicking the
RETURN TO MERCHANT WEBSITE
button, you will be redirected back to our website to complete the INTAKE REGISTRATION FORM.
Completing the INTAKE REGISTRATION FORM IS REQUIRED
in order to complete your Anger Management class registration and enrollment. The intake form takes about 10-15 minutes to complete. Once the form has been completed and submitted, an Anger Management Facilitator will contact you to schedule a time/day for an INTAKE INTERVIEW.
Initial below to indicate that you have read and understand these terms and instructions:
Would you like to receive a copy of your completed forms via email. If, yes enter email below: