Online Payment
Make a payment on an existing account. To schedule an evaluation, assessment or intake, please call our office!
CLIENT'S NAME (If you are paying for someone else, please type that person's name here.)
*
First Name
Last Name
E-mail for receipt
*
example@example.com
What is this payment for?
*
Payment
*
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USD
Payment
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: