Please read and completely fill out the form below. Once we have received your completed Payment Agreement, we will contact you to schedule future appointments. Your card information is confidential.

By completing and signing this Payment Agreement, you are indicating that you understand and agree to make a payment upon each appointment via Zelle, Venmo or Cashapp. 

Your signature indicates you understand that if you do not attend a scheduled appointment you will be charged the regular session fee unless you cancelled your appointment at least 24 hours in advance, business days – Monday through Friday; for cancellations with less than 24 hours notice, the full session fee will be charged. For missed appointments with no notice given, the full session fee will be charged.

Your signature indicates that you understand that you, not an insurance company or other 3rd party payer, will be paying for your sessions, and any missed or late-cancelled appointments.

Payments are expected at the time of service or in advance of service. Your signature indicates that if you don’t pay by another form of payment at the time of service, you will be sent a reminder email or text. You will not receive service until payment is made. 

Your signature indicates that you may be charged for other services such as extended phone calls, consultation on your behalf, and other services rendered on your behalf. These charges will be discussed with you ahead of the services provided.