Women's Therapy Group Form

Women’s Therapy Groups (Virtual)

Mona holds that every woman has the power to connect to her intuition, overcome challenges in her life and actualize her highest potential. That is why Dr. Mona Shenassa Toubian shares her therapeutic methodology called Soul Work Evolution™ — which has transformed the lives of many women.
Name*

First NameLast Name
Email*
example@example.com

Please rank your preference for group therapy below (please pick your first, second and third option, as there is a possibility that your first or second choice may be full):

	Rank (1st, 2nd, and 3rd choice)
Group A: Meets on Tuesdays @ 9am-11am (PST)
Group B: Meets on Tuesdays @ 6pm-8pm (PST)
Group C: Meets on Wednesdays @ 5pm-7pm (PST)
Group D: Meets on Thursdays @ 11am-1pm (PST)

Mobile Phone*
Please enter a valid phone number.
Credit Card Authorization
I, {name} authorize Dr. Mona Shenassa Toubian to charge my credit card for any services rendered as agreed to. I also authorize MST International Inc. to charge my card in the event I fail to show for a scheduled appointment, or do not give notification of my inability to attend a scheduled appointment at least 72 business hours in advance. I further authorize MST International Inc. to disclose information about my attendance/cancellation to my credit card company if I dispute a charge. I acknowledge that I am aware there is a $25 fee for any declined credit card charge (or $35 for a bounced check).

* I agree to have my credit card automatically authorized for $650/month for the group therapy sessions. There will be no prorated or deducted fees for 2 hour weekly sessions that are missed.
** I agree to a three-month commitment in order to maintain optimal cohesiveness and benefit to the group members.
*** Dr. Mona does not take insurance directly but works with “Advekit” which is a platform that can help you understand and use your Out-of-Network insurance benefits. If you make a free account with this service, they will link you with me and will pay me on your behalf. Advekit will only charge you the balance of what your insurance does not pay. So, once you meet your deductible, they only charge you what you owe and they wait for reimbursement instead of you having to wait. This also means that you will no longer have to file insurance claims or paperwork because they will do it for you! Their goal is to make it easier for both of us so we can focus on your care. There is 12% transaction fee added to price for using this option which Advekit charges.

Please select a class / time below: *

Group A: Meets on Tuesdays @ 9am-11am PST (2 Hours/Week)

$650.00 for each month

Group B: Meets on Tuesdays @ 6pm-7pm PST (1 Hour/Week)

$450.00 for each month

Group C: Meets on Wednesdays @ 5pm-7pm PST (2 Hours/Week)

$650.00 for each month

Group D: Meets on Thursdays @ 11am-1pm PST (2 Hours/Week)

$650.00 for each month

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

*Cancellations must be made at least 72 hours in advance or fee must be paid in
full and I am aware there is a $25.00 fee for declined credit cards (or $35 for a
bounced check). This form will be securely stored in your clinical file and may be updated upon request at any time. Please note, your credit card will not be charged unless the following conditions apply: Therapy session was attended by you, the client, or you were a no-show for a scheduled appointment, or you failed to cancel less than 72 business hours in advance, allowing us to reschedule other clients in the
session slot.
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Date*

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Women’s Therapy Groups (Virtual)

Credit Card Authorization