Therapy Session Payment
Payments are due 24 hours in advance of your scheduled visit. Cancellations without a 24 hour notice are not refundable.
Session For
*
First Name
Last Name
Scheduled Session Date
*
-
Month
-
Day
Year
Therapist Name
Payee Name
*
First Name
Last Name
Payee Phone Number
*
Payee Email
*
Select one of the following. (One visit per payment transaction)
*
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1 Hour Session
$
108.15
2 Hour Session
$
216.30
3 Hour Session
$
324.45
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