The Counseling Shop

The Counseling ShopThe Counseling ShopThe Counseling Shop

The Counseling Shop

The Counseling ShopThe Counseling ShopThe Counseling Shop
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    • Home
    • About Patty
    • Services
    • Fees
    • Forms
    • Contact Us
  • Home
  • About Patty
  • Services
  • Fees
  • Forms
  • Contact Us

ELECTRONIC PAYMENT AUTHORIZATION

Electronic Payment

Please complete the following information. Session fees for all clinical treatment will be deducted from the account designated on this form. (This includes balances that your insurance does not cover, but for which insurance says you are responsible.) Forms of payment accepted: Visa, MasterCard and Discover. This form will be securely stored in your clinical file and may be updated upon request at any time.

ELECTRONIC PAYMENT AUTHORIZATION FORM

* Required Field

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The Counseling Shop

11224 86th Ave N, Maple Grove, MN 55369

763-400-7075

Copyright © 2020  Patty Hill, LISCW. Phone: 763-400-7075  - All Rights Reserved.

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