Facility Creation Form – Reconnect, Inc.

Thank you for your interest in Reconnect.

Once you fill out this form, we’ll create your Reconnect facility.

Contact Information
Primary Contact Name*
First Last
Primary Contact Email*
Primary Contact Phone*

Billing info
PLEASE NOTE: This information will only be used in the event you commit to using Reconnect's services and does not constitute a formal agreement.
Billing Contact Name*
First Last
Billing Contact Email*
Billing Contact Phone*
Billing Contact Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Payment Options
Payment type*
- Program Pay (my program will pay for services)
- Client/Participant Pay (participants will pay for services)
Hidden
Preferred billing method
- Invoice via email
- Invoice via postal mail
- Credit card on file