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JC Christian Counseling
1821 Oregon Pike Suite 212 / Lancaster, PA 17601 / Office: (717) 278-8326 / Fax: 1- 866-285-7198
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On-Line Termination of Services and Refund Form
 
I, am terminating services for
as of due to
 
I am also requesting to be refunded the money that is owed to me (if any) according to the Counseling Policy.
 
Client Name:
Respopnsible Party:
Witness:
Client Signature: Click Here to Sign
 
 
 
 
 
 
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