Visit Payment Form

Thank you for making a secure payment for your visit. If you encounter any issues or have any questions about payment, please contact Kara at 737-204-5610

Question Title

* 1. Please provide your contact information, below.

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

Question Title

* 2. I am paying for a scheduled visit:

Initial Intake Evaluation with MD - 60 minutes - $400 USD

Brief consultation or followup (less than 10 minutes) - $50 USD

Followup visit with MD - 15 minutes - $100 USD

Followup visit with MD - 30 minutes - $200 USD

Followup visit with MD - 45 minutes - $300 USD

Followup visit with MD - 60 minutes - $400 USD

Session with Therapist - 50 minutes - $125 USD

Please provide the date and time of the appointment for which you are paying.

You will pay at the end of this survey.