Patient Notebook

Patient Information

First Name *

M.I.

Client/Patient Name

Last Name *

Account # *

Found on Statement from Crosswinds Counseling and Wellness; Alphanumeric ending in F0 or M0

Phone Number *

You may be contacted if your account can not be located.

Statement Date

Email Address

A receipt can be sent to this email address after payment confirmation.

Payment Information

Make A Payment

Amount is required.

Installment Amount must be equal to or greater than the Minimum Installment Amount shown.

Installment Amount exceeds the Plan Balance.

You cannot set up a payment plan without submitting a valid email address.

First Payment Date is required.

Payment plans must start today or later.

Payment plans must start within one year.

First Payment Date is invalid.

How would you like to pay?

One-time Payment

Amount *

This payment will be made to Crosswinds Counseling and Wellness

Choose a Payment Method

+ Bank Account

+ Credit/Debit Card

Bank Account

Change

Account Type *

Routing Number *

Bank Account Number *

Bank Name On Check *

Bank Check Number *

Credit/Debit Card

Change

Name on Card *

Card Number *

Expiration Date *

Security Code *

Zip Code *

Cancel