Credit Card Authorization

Credit Card Authorization Form


* Costs of Treatment Financial Contract

  • All fees are non-negotiable and due and payable at time of admission.
  • By signing this contract as the responsible party for treatment fees. I further understand that all fees paid are non-refundable regardless of length of stay.
  • Deposits and payments are non-refundable & non-transferable.
  • No verbal agreement will supersede this contract.
  • I hereby agree to hold Rising Roads harmless for any and all future claims resulting from this contract.

A&E Intervention

Confidential Contact Form

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