Skip to content
Talk to Someone Now at
1-866-746-1558
Facebook
Instagram
Twitter
Search for:
HOME
ABOUT US
Staff
Gender Specific Treatment
Mission
Our Sanctuary
Blog
MENTAL HEALTH
ADDICTION
OUR LEVELS OF CARE
Residential Extended Aftercare
Outpatient Rise Program
PROGRAMMING
Treating Trauma
What is Emotional Trauma?
Brainspotting
EMDR
Accelerated Resolution Therapy
Psychiatry
Expressive Art Therapy
Psychodrama
Family Therapy
Individual and Group Therapy
ELEVATE School Program and Career Testing
Employment Assistance
Life Skills
Nutrition
DBT Skills
Healthy Relationships
Sober Fun
FOR FAMILIES
Video Resources
Book Recommendations
FAQ’s
ADMISSIONS
Insurance Verification
Initial Intake Form
Financial Form
HIPAA Policy – Protected Health Information
Privacy Policy
CONTACT
Loading...
Financial Form
admin
2022-05-16T23:36:55+00:00
CREDIT CARD AUTHORIZATION
Credit Card Authorization Form
"
*
" indicates required fields
Type of Card:
*
Personal Card
Corporate Card
Client Name:
*
Email Address:
*
Daytime Telephone:
*
Fax Number:
Treatment:
*
Admin Fee/ Bed Deposit (Non-Refundable)
1st Month (Residential Extended Care)
2nd Month (Residential Extended Care)
3rd Month (Residential Extended Care)
PHP - Partial Program
IOP - Intensive Outpatient Program
OP - Outpatient Program Phase 1
OP - Outpatient Program Phase 2
OP - Outpatient Program Phase 3
Los Pesos Transitional Living
Career Testing and Personality Report
Elevate School Program
Covid Test
Miscellaneous
Amount
*
Billing Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Credit Card
*
Card Details
Cardholder Name
Today's Date:
Financial Contract for Cost of Treatment
All fees are non-negotiable and due and payable at time of admission.
By signing this contract as the responsible party for treatment fees. I further understand that all fees paid are non-refundable regardless of length of stay.
Deposits and payments are non-refundable & non-transferable.
No verbal agreement will supersede this contract.
I hereby agree to hold Rising Roads harmless for any and all future claims resulting from this contract.
Costs of Treatment Contract
*
I have read and agreed to the above Terms and Conditions.
I have contacted my credit card provider and placed approval on file for the above submitted Rising Roads program cost.
Comments
This field is for validation purposes and should be left unchanged.
Δ
Talk to Someone Now at
1-866-746-1558
2750 S Harbor Blvd, #G, Santa Ana, CA 92704
Page load link
Go to Top