Therapy or Therapeutic Visitation 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
*
Format: (000) 000-0000.
Payee Email
*
Select one of the following (Only one visit per transaction)
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next
( X )
1 Hour Session
$105/hr plus paypal fees
$108.15
$
108.15
2 Hour Session
$105/hr plus paypal fees
$216.30
$
216.30
3 Hour Session
$105/hr plus paypal fees
$324.45
$
324.45
30 minute session (prior approval needed)
$52.50 plus paypal fees
$54.08
$
54.08
Quantity
1
2
3
4
5
6
7
8
9
10
PayPal Payment
Should be Empty: