Welcome To Pennsylvania Counseling Services
Client EasyPay Portal

This pay option is provided as a way to make it easy to make a payment on your account
without mailing a check or having to stop by the office to drop off a payment.

Please fill out and submit the below form to make a payment.

All fields marked with a (*) are required.

Payment Type

Please select the type of payment being made: *

Client Information

Client First Name *

Client Last Name *

Client Date of Birth (in the format: mm/dd/yyyy) *

Clinic Location *

Additional Information

Payor Phone Number *

Name of person making payment (if different from client)  

Payment & Credit Card Information

Enter Amount in US Dollars($) *

First Name on Credit Card *

Last Name on Credit Card *

Credit Card Type *

Credit Card Number (No Dashes or Spaces) *

Credit Card Expiration Date *

Credit Card Security Code *

Street Address *

Street Address (Line 2)  

City *

State *

Zip Code *

NOTE: Your credit card statement will show the payment description as

Secure checkout powered by PayPal