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
Alex Moskovich
Anita Gushurst
Christopher Lundell
Chelsea Carter
Courtney Greif
Debbie Tomasovic
Gina Kanagawa Schwartz
Julie Archer
Julie Archibald
Kyrie Campbell
Magen Weeldon
Marieke Brown
Tina Powell
Session Payment/Copay Payment Amount:
*
prev
next
( X )
Amount
Please Select Amount From the Drop Down Below
$
Free
Amount
$0
$184.16
$180
$159.79
$150
$120
$117.81
$110
$100
$95
$93
$91.21
$90
$85.25
$85
$80
$75
$70
$65
$60
$55
$50
$45
$41.20
$40
$36.83
$35
$30
$25
$24.58
$20.00
$18.24
$17.88
$15.00
13.88
$12.36
10.00
8.56
4.56
Quantity
Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Date
Postal Code
Enter Email Address Here for Receipt to be Sent
example@example.com
Any Additional Information for the Office to Know:
Submit
Should be Empty: