Provider Billing Forms

Thank you for the work you do in serving couples through Kingdom Family Ministry. Your commitment to strengthening marriages and families makes a lasting impact in our community, and we are truly grateful for your partnership.

Please note that all billing forms are processed every Thursday. Payments are issued within 48 business hours following processing.

If you have any questions regarding billing or documentation, please contact Robert at Robert@kingdomfamilyministry.org. We appreciate your dedication and your continued service to the couples we support.

Marriage Support Billing Form

Pre-Marital Support Billing Form

Marriage Support: Provider Billing Form

Marriage support services may be billed for up to nine sessions per couple. An evaluation form must be submitted after the sixth session in order to receive authorization to continue with the remaining three sessions. A final evaluation form is required after the final session.

Go Here For The Premarital Support Billing Form.

Kingdom Family Ministry Marriage Support Program

Date

Month

Day

Year

Company name

First name

Last name

Phone

Client Information

Counseling Session Date

Husband: First & Last Name

Wife: First & Last Name

Counseling Session Length (Note: KFM will only pay for one hour of counseling)

Were husband and wife both in attendance?

What Counseling Session Was This?

Do you plan to continue counseling with the client?

I understand I must receive prior approval for sessions 7, 8, & 9. One time approval for all three session can be requested by completing the following evaluation form after the sixth session. www.kingdomfamilyministry.org/providerevaluationform

Yes

Please confirm session rate recorded on your provider application

Payment Information

Preferred Payment Method

Check payable to and mailing address if applicable

Zelle information if applicable

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Has any of the billing information changed? If so, indicate the change below.

Payment mailing address

Zelle Account Information

Thank you for all you do to build kingdom marriages!

Pre-Marital Support Provider Billing Form
Premarital support services may be billed for up to six sessions per couple. A final evaluation form is required after the final session.

Go Here For The Marriage Support Billing Form.

Kingdom Family Ministry PreMarital Support Program

Date

Month

Day

Year

Company name

First name

Last name

Phone

Client Information

Counseling Session Date

Client 1: First & Last Name

Client 2: First & Last Name

Counseling Session Length (Note: KFM will only pay for one hour of counseling)

Were Both Clients In Attendance?

What Counseling Session Was This?

Do You Plan To Continue Counseling With The Client?

Payment Information

Premarital counseling is $75/ per session for six sessions.

Preferred Payment Method

Check payable to and mailing address if applicable

Zelle information if applicable

Has any of the billing information changed? If so, indicate the change below.

Payment Address

Zelle Account Information

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Thank you for all you do to build kingdom marriages!

Provider Billing Forms

Marriage Support: Provider Billing Form

Go Here For The Premarital Support Billing Form.

Kingdom Family Ministry Marriage Support Program

Client Information

Payment Information

Pre-Marital Support Provider Billing Form Premarital support services may be billed for up to six sessions per couple. A final evaluation form is required after the final session.

Kingdom Family Ministry PreMarital Support Program

Client Information

Payment Information

Pre-Marital Support Provider Billing Form
Premarital support services may be billed for up to six sessions per couple. A final evaluation form is required after the final session.