Pay Bill

We use PayPal to process these payments, and you will receive an email confirmation of your payment.
Unless specified in the Details box below, payment made here will be applied to the oldest outstanding balance on the patient’s file.
If you select your therapist’s email below, they will also receive an emailed confirmation of your payment.

This web form is secure and encrypted to protect your personal information
Your data is kept strictly confidential

Patient Name

First

Last

Date of Birth

This payment is for:

Email

For emailed receipt of payment

Amount to pay:

Details regarding your payment

Name Patient or

Therapist's Email

If you want your therapist to receive a notification of your payment, select their email address above,

Credit Card or PayPal

Card Number

Expiration Date

Security Code

Cardholder Name

Billing Address

Address Line 1

City

State

Zip Code

Authorizations