Secure Payment Form

The Change Group

Full name as it appears on card(required)
Billing Street Address(required)
City(required)
State(required)
Zip Code(required)
Phone Number(required)
Email(valid email required)
Which Program Option Do You Choose? (Note: Any programs other than 90-Days to Change or Substance Abuse Assessments should be selected as "Individual Program")(required)
Credit Card Type(required)
Credit Card Number(required)
Expiration Date (MM/YY)(required)
CVV (3 Digit # on back of card) NOTE: AMEX Users, please enter the 4-digit # on the front of your card.(required)
The above information is accurate and that it is my own payment information. Further, I consent to The Change Group's Terms of Service and agree that they should charge my card according to the Payment Plan I indicated above. I also agree to abide by the terms indicated in my informed consent documents.(required)
Please tell us where you heard about us:(required)