Payment by Check for Intensive Therapy Weekend

To make a payment to Colorado Center for Couples and Families, please provide the following information:

Name of Account Holder*

First Last

Email*

Phone*

Account Type*

Routing Number*

Account Number*

Date and cost of intensive weekend I am purchasing:*

Agreement*

By checking this box and clicking the Agree and Submit button below, I authorize Colorado Center for Couples and Families to initiate either an electronic debit or to create and process a demand draft for the amount indicated above, against my bank account, the information for which is also above. I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law. I also acknowledge my understanding that this payment is non-refundable.

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