Online Payment

You may pay for an upcoming visit or an outstanding balance with a secure transaction online.

If you currently see a Peachtree DBT clinician, you may use this payment form to make a DBT skills class payment after registration is closed. When making a DBT skills class payment, please be sure to enter the module name, class day, and class time in the note section under patient information.

If you have any questions or need help, please email us or call 404-351-2008.

Asterisks (*) indicate required fields

Patient Information

Patient Name *

Patient Date of Birth *

Month

Day

Year

What is this payment for? *

Balance

Pre-payment

Overdue Class/Group Payment

Other

Note

Account Number

(not-required)

Statement Number

(not-required)

Payment Details

Person who will be submitting payment

First Name *

Last Name *

Address *

Address 2

City *

State *

Postal Code *

Phone *

A phone number where we can reach you if there is a problem or question.

Email *

An email where we can reach you if there is a problem or question.

Payment Amount *

The amount you will be paying.

Leave this field blank