Payment Form

Please correct the errors described below.

Fees: $200 per 45-60 minute Session $240 Initial Diagnostic Session(s) or amount told otherwise Cancellation Policy: We have a 24 business hour cancellation policy. We hold times in our schedules just for you. If you need to cancel for any reason with less than 24 business hours there will be a charge of $50. We will gladly waive the fee if the opening created by your cancellation is filled.
You authorize your credit card* to be charged for any late cancellation fee, returned checks or unpaid insurance. We will routinely charge your credit card for unpaid co-pays and insurance. We send statements only on request.
Please provide your CREDIT CARD NUMBER, EXPIRATION, and SECURITY CODE BELOW (Please note that if we receive a hard copy of your payment information we put it into your secure EHR file and immediately shred the hard copy).

Your information will be encrypted.