Search for: PoliciesPrivacy Policy Terms and Conditions of Use Refund Policy Your information is secure Rest assured, your payment and your personal informaiton are secure. We strictly follow the HIPPA compliance guidelines and the industry standards on data security. Please review our Refund and Privacy policies above. Secure Payment First Name* Last Name* Phone E-mail iPlease provide an e-mail address if you wish to receive a copy of your receipt in your inbox. Service Date iDate when the service you are paying for was rendered or will be rendered. Service Type* ---- Select one ---- Individual Session Late Cancellation Fee Cognitive Remediation Consultation--Other Treatment--Other Assessment--Neuropsych Assessment--Psychodiagnostic Assessment--Psychoeducational Billing Address Address* City* State* Zip Code* Payment Payment Type* ---- Select one ---- Co-pay Full Session Partial Assessment payment Full Assessment payment Payment Amount* Payment Method* ----Select one---- Visa MasterCard American Express Discover JCB Diners Club Credit Card Number* Expiration Date (MM/YY)* Security Code* i 4-digit in the front for AMEX or 3-digit in the back for all others. Please click the button only once and wait for the system to process. Clicking multiple times may result in multiple payments. All fields marked with * are required.
