Therapy Payment Form
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Client Name
*
First Name
Last Name
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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
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Therapist Name
Alex Moskovich
Anita Gushurst
Caleb Merryman
Callie Cheary
Cheryl Garman
Colette Lynch-Sajo
Courtney Greif
Debbie Tomasovic
Gina Kanagawa Schwartz
Hannah Martin
Heidi Nolan
Jacqueline Lounsbury
Julie Archer
Julie Archibald
Kat Williams
Kyrie Campbell
Laura Aubert
Lauren Salerno
Magen Brown
Nicole Parsons
Tina Powell
Wendy Scott
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Session Payment/Copay Payment Amount:
*
prev
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
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Enter Email Address Here for Receipt to be Sent
*
example@example.com
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Any Additional Information for the Office to Know:
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Submit
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Should be Empty: