Payment Form

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If you have a child, parent, friend, or loved one in one of our treatment facilities, you can easily send money to them directly using the Payment Form below.

"*" indicates required fields

Your Name*

First Last

Client's Name*

First Last

Amount*

Total

Secure Credit Card

Card Holder*

Card Number*

Card Expiration*

Card CVV*

Reason / Comments*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone

Rockland Treatment Center does not provide refunds of any monies paid by or on behalf of the client if the client leaves treatment against medical or clinical advice or is administratively discharged. Any incidental monies received and applied and or used will not be reimbursed if credit card was used to pay for said items. IF a credit card was used for payment of services offered at the center and a client leaves early due to an inadvertent situation, your stay will be pro-rated for your visit and any unused portion will be credited back through the credit card used to pay for said services whether it was your actual credit card or that of your friend, family or employer.

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Payment Form

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