Harris Center Telehealth

Name of Person Receiving Service

First Name *

Last Name *

Date of Service *

Month

Day

Year

Contact Information

Check if the contact person is different from the person receiving service (listed above)

Contact First Name *

Contact Last Name *

Email Address *

Phone # (optional)

Type of Service *

(select all that apply)

Individual Therapy

Group

Psychological Testing

Other

Other *

Amount to be paid (USD) $ *

Clicking "Continue to Online Payment Form" will take you to the external merchant who is handling online payment transactions on behalf of the Harris Center. Please note that this transaction is not complete until the payment is processed. Email us at HarrisCenter@uky.edu if you have any questions or issues with completing this form.

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Harris Center Telehealth