Update Credit Card Information:

SOUTH TAMPA THERAPY & MEDIATION ADMIN TEAM:

Nancy Araven, MA, LMHCI, NCC 813-421-5465
 
Elizabeth Mahaney, LMHC, MFT, NCC, Ph.D. 813-240-3237  
Florida Supreme Court Certified Family Law Mediator  
Qualified Supervisor for MHC, MFT, CSW Interns
 
 www.SouthTampaCounselor.com
SouthTampaTherapy@gmail.com

Sign in to Google to save your progress. Learn more
Email *
Updated Client Financial Form
Phone* *
Full Name On Credit Card * *
Credit Card Number * *
Zip Code * *
Expiration Date * *
Security Code CVV # (3 numbers on back of card) * *
FINANCIAL AGREEMENT                                                                                                                                      Credit Card Number on File:    Elizabeth Mahaney (and therapists at South Tampa Therapy) respects your time and sets aside time to see you when you make an appointment. A session usually lasts 50 minutes and payment is due at the time of treatment. It is important that clients respect the therapist’s time as well.  Clients wishing to cancel or change an appointment must give the counselor 24-hours notice.  In most cases, the therapist will be able to accommodate another client if such notice is given. To impress upon clients the importance of giving advance notice when canceling appointments, the counselor requires a credit card number and information on file. If a client no-shows or cancels at the last minute or without giving 24 hours notice so that the slot may not be taken by someone else who is waiting for therapeutic care, the credit card will be charged for the full cost ($160) of the missed appointment.                                                                                       In addition, if INSURANCE is used and you cancel without 24 hour notice you will be charged $75. Once again, be warned – clients who miss appointments or cancel without 24 hours notice will be charged for a full missed appointment based on the hourly rate. Please provide credit card information here. Elizabeth Mahaney will be very respectful of this information and your rights to privacy. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms