Session Fee Payment

Name of Client*
First Last
- Individual Session
- Couple Session
- Family Session
Phone Number*
Email*
Date of Session*
Date Format: MM slash DD slash YYYY
- I am paying for more than one session.
Date of Session*
Date Format: MM slash DD slash YYYY
Date of Session
Date Format: MM slash DD slash YYYY
Name of Therapist*
Total Fees Owed*
Please enter the amount of your session fee. If you are paying for multiple sessions, please indicate the TOTAL amount of your payment.
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country