Therapy Payment Form
Client Name
*
First Name
Last Name
Session Date
*
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
15
30
45
Minutes
AM
PM
AM/PM Option
Therapist Name
*
Anita Gushurst
Brandi Schultz
Caleb Merryman
Callie Cheary
Cheryl Garman
Colette Lynch-Sajo
Connor O'Bryan
Debbie Tomasovic
Hannah Martin
Heidi Nolan
Jamee Shermer
Julia Schetky
Julie Archibald
Kat Williams
Kathy Cox
Kylie Young
Kyrie Campbell
Lauren Salerno
Laura Aubert
Megan Parrott
Melissa Cantwell
Michael Maini
Nicole Parsons
Scott Groseclose
Stephen Taylor
Tina Powell
Tucker Gerhardt
Wendy Scott
Session Payment/Copay Payment Amount:
*
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next
( X )
Amount
$
Free
Quantity
Amount
Select
$180
$165
$150
$120
$110
$100
$90
$80
$70
$60
$50
$40
$35
$30
$25
$20
$15
$14.37
$10
Credit Card
Enter Email Address Here for Receipt to be Sent
*
example@example.com
Any Additional Information for the Office to Know:
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