BALM FAMILY RECOVERY PROGRAM

Full Name *

Email *

Phone *

Who referred you?

Experience the BALM which includes weekly group coaching:

12 months of BALM Family Recovery Education and weekly Group Coaching - $2400

6 months of BALM Family Recovery Education and weekly Group Coaching - $2000

Option 33 months of BALM Family Recovery Education and weekly Group Coaching - $1800

And, if you would like to have your own coach to walk the family recovery path with you, You can experience the BALM along with personal guidance from a coach you meet and work with weekly:

12 months of BALM Family Recovery Education and weekly one-on-one coaching $10,000

6 months of BALM Family Recovery Education and weekly one-on-one coaching - $6000

3 months of BALM Family Recovery Education and weekly one-on-one Coaching - $3500

I agree to pay right away through the following means:

Zelle - to [email protected]

ACH (write your routing number and your account number in the space provided below and we will withdraw the amount once or monthly)

Check made out and mailed to Family Recovery Resources, LLC, ℅ Beverly Buncher, 6698 Tenth Ave N Apt 318, Lake Worth, FL, 33467

If you are using ACH, please provide your routing number

And your account number

Signature

Clear

Date Signed

Please sign and submit this agreement which will indicate the:

Item or service you paid for
Amount paid/agreed to
Form of payment
Payment information
Your signature

Please complete payment upon completion of this form. As soon as we get your confirmation, we will enroll you.

If you have any questions or concerns, please feel free to contact Bev at [email protected] or call me at 786-859-4050.

I CERTIFY THAT I HAVE READ, SIGNED, AND EMAILED THE PROGRAM AGREEMENT TO THIS PAYMENT FORM AND UNDERSTAND THAT THE INFORMATION ON THE AGREEMENT AND THIS FORM ARE BINDING.

I CERTIFY THAT THE ABOVE STATEMENTS AND INFORMATION MADE IN THE AGREEMENT AND ON THIS FORM ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND THAT I WILL PAY THE AMOUNT(S) AGREED TO AS AGREED.