CheckMate CheckMate Counseling Application & Payment Form Name* First Last Email* Enter Email Confirm Email Reason why you visited the website today?*----select one----Interested in Purchasing a CheckMate Lesson Guide (Couples' Packet) OnlyInterested in Our Onsite and/or Video Counseling ServicesInterested in Making a Payment for a Scheduled Onsite and/or Video Counseling SessionPreferred Duration of Relationship Services?*----select one----4 weeks (4 sessions)8 weeks (8 sessions)Important Note: There will be one (1) counseling session per week. Each session will last 1.5hrs and will cost $75.00. A $2.55 charge will be added to cover electronic payment processing fees (if applicable). This fee will be due no later than the day before the scheduled onsite and/or video counseling session. We will be in touch with you shortly to schedule your first session.Payment For Scheduled CheckMate Counseling Session* Price: $77.55 Quantity: Important Reminder: There will be one (1) counseling session per week. Each session will last 1.5hrs and will cost $75.00. A $2.55 has been added for electronic processing fees. This fee will be due no later than the day before the scheduled onsite and/or video counseling session. If you prefer to avoid the electronic processing fee, send your payment to the following: Send Cash App payment to: $TEMPLEMACAddress (Onsite Visitation)* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CheckMate Lesson Guide (Couples' Packet)* Price: $52.50 Quantity: Important Note: The Couples' Packet includes two (2) CheckMate Lesson Guides. A $2.50 charge has been added to cover electronic payment processing fees. If you prefer to avoid the electronic processing fee, send your payment to the following: Send Cash App payment to: $TEMPLEMAC