Weekly Payment Agreement

Use the link below to complete the weekly payment form. Note: You will be redirected to our secure form completion software.

We’re Here For You

Simply fill out the form and we’ll be in touch soon.

Call or Text Us

Questions or not sure what next step to take? We’re here for you! During our working hours you’ll likely be able to connect with someone on our admin team immediately.

Get in Touch Today

"*" indicates required fields

First Name*

Last Name*

Email*

Phone*

Select Preferred Location*

State of Residence?*

If not in the US select "International"

Are you or the client(s) covered by Medicaid, CHP+ or a Medicare disability plan?

* We do accept some Medicaid plans, but will need to verify benefits.

Medicaid ID Number*

Date Of Birth*

How can we help?*

How would you like to be contacted?*

Phone

Text

* You will also receive a confirmation text and email upon submitting this form.

Do you consent to receiving text messages from Cornerstone Christian Counseling?*

Yes

*By checking YES, you agree to receive text communication from our office and billing teams.

Are you a robot?

Cornerstone accepts CCHA Medicaid but does not bill other insurances. We do provide superbills for potential reimbursement.

If you are experiencing a mental health emergency, including thoughts of harming yourself or others, please call 911 or go to your nearest emergency room immediately. You may also call the National Suicide Prevention Lifeline at
800-273-8255.

CO: (303) 902-3068 (call or text)
FL: (904) 439-4400 (call or text)

Careers: We’re Hiring!