Marriage Support
Provider Billing Form

Kingdom Family Ministry Marriage Support Program

Date

Month

Day

Year

Company name

First name

Last name

Phone

Client Information

Counseling Session Date

Client 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 4, 5, & 6. Approval can be requested by completing the following evaluation form after the third session. https://www.kingdomfamilyministry.org/providerevaluationform

Yes

Please confirm session rate recorded on your provider application

Mailing Information

Make Payment Payable To:

Mailing Address

Signature

Signature field is empty.

Thank you for all you do to build kingdom marriages!

Marriage Support Provider Billing Form

Kingdom Family Ministry Marriage Support Program

Client Information

Mailing Information

Marriage Support
Provider Billing Form