Donation Form

Payment with Kids House

For all counseling, group counseling (i.e. TEG, CPRT group), EMDR consultations payments. Please be sure to select service type and include the date of service, client's, therapists name, and any other additional info in the Memo.

Service Payment Type

Memo

Type of Payment

One Time PaymentRecurring Payment

Contact Information

First Name

Last Name

Company Name

Address

Address 2

City

State/Province

Zip/Postal Code

Home Phone

Cell Phone

Work Phone

Payment Information

Card Holder Name

Card Account Number

Expiration Date

Security Code

Billing Address

Same As Above

Address

Address 2

City

State/Province

Zip/Postal Code

Privacy Policy
We take precautions to protect your information. We collect credit card or bank account information, names, addresses, and other data related to your transaction when you make a payment through our site. We use this information to process your payment.

Terms/Conditions
By submitting your payment, you authorize us to charge the account above for the amount specified in the Transaction Amount field. In the event of a Recurring Pledge or Monthly Giving, payment information is encrypted and stored securely via SafeSave™ for automatic processing of your future payments. Notify us at anytime if you wish to discontinue your pledge.