Pay Online

You can use this form to pay for transitional housing or treatment fees.

If you do not receive a payment confirmation, do not resubmit your payment. Please contact Sue at 734.485.8725.

Name of the person you are paying for?
First Last
What are you paying for?
transitional housing, residential treatment, outpatient services
Amount*
Please enter your payment amount.
Billing Name*
First Last
Billing Email*
Billing Address*
Street Address City State ZIP Code
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Please enter Credit Card number without spaces or dashes (“-“). Expiration Date Security Code Cardholder Name
Payment Total
$0.00
Consent*
This form collects your name, email, phone, address, and billing information so that we can process your credit card transaction through PayPal our payment processor. Check out our Privacy page for details on how we protect and manage your submitted data.
- I consent to have this website collect my details via this form.
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Comments
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