The Counseling Center 
                                                            One Main Street * Nashua, NH 03064   (603) 883-0005                                    
                                                            148 Coolidge Avenue * Manchester, NH  03102 * (603) 627-3111
                                                            294 D.W. Highway * Merrimack, NH  03054 * (603) 883-0005
                                                            50 Nashua Road * Suite 305 * Londonderry, NH  03053 * (603) 432-3033
                                                           208 Robinson Road * Suite 204 * Hudson, NH  03051 * (603) 598-9958
                                                           45 Main Street * Peterborough, NH  03458 * (603) 924-3331
                                                           61 NH Route 27 * Unit 10 * Raymond, NH 03077 * (603)689-7602
                                                           
414 State Street * Unit 2 * Portsmouth, NH  03801 * (603) 334-2533
                                                           24 Front Street * Suite 304 * Exeter, NH 03833 * (603) 778-2005  
                                                           16 Lincoln Street * Suite C * Brunswick, ME 04011 * (207) 406-4222
                                                           319 Whittier Highway * Suite 8 * Center Harbor, NH 03326 * (603) 546-6178 
                                                                                          Fax all locations: 603-883-0007

Long Term Payment Agreement

Please note the following criteria must be met in determining an acceptable payment plan:

1.An initial good faith payment is due upon the signing of a payment plan in miminum amounts as follows: If your balance is up to $200, a minimum of half is required; if balance is over $200 a minimum of $100 is required now

2. If balance is $200 or less, payment must be completed in two month; if $200-$400 payment must be completed in 3 months; if over $400 it must be completed in 4 months.

3. If you are continuing in care, payments on outstanding balances must be in addition to remaining current on ALL ongoing costs of future care (i.e., payment for new services are due in full at the time of each service, and cannot be added to the existing outstanding debt on your account);

4.  If you cannot complete payment per the criteria above, please schedule yourself into our online billing department schedule to speak with someone regarding a payment plan 
 
Schedule an Appointment to Talk to Billing
 
Based upon the above criteria, please complete the following:


Method of Payment: *

Regular Payment Plan:
Method of Payment:
Method of Payment:

Visa
Security codes are
found on the back
of the card or front
of the American Express
Additional information or intructions pertaining to payments or use of credit card. 
In addition to my current payment above, I would like to leave my Credit Card information on file for future payments. 
Please check any/all requests for future use of your credit card
Future Co-Pays and Balances Due - if not otherwise paid for in person at the time of your visit *
~~By selecting 'Yes' you are agreeing to all future co-pays and balances being charged to this credit card.~~ *
* If yes and you have submitted an FSA or HRA card, please also consider submitting a regular credit or debit card to cover when your FSA or HRA is depleted.
Charges for medication refills requested by phone
* If yes and you have submitted an FSA or HRA card, please also submit a regular credit or debit card for non-insurance billable services
Long Term Payments per Payment Plans, if applicable
Educational Liaison Services
* If yes and you have submitted an FSA or HRA card, please also submita regular credit or debit card for non-insurance billable services
Testing Co-Insurances
Non-Covered Charges for Educational Testing or Comprehensive Report Writing.
* If yes and you have submitted an FSA or HRA card, please also submit a regular credit or debit card for non-insurance billable services
calendar
I understand that my typed name above shall have the same legal and binding authority as my handwritten signature.