I.C.A.R.E | Secure Payment Form

Order Date: 03/04/24
Client First Name: *
Client Last Name: *
Date of Birth: *
Email Address:
Customer ID:
Date & Time of Service: *
Program: *
Counselor's Name: *
Amount: *
Credit/Debit Number: *
Name on Card: *
Card Billing Address: *
Card Billing Zip: *
Card Expiration Date: *

You will be prompted to print your receipt after making your online payment. If you are not able to print your receipt, a receipt can be emailed to your address on file upon your request.