Credit Card Payment Form

Billing Information
First Name:
Last Name:
Phone#:
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Email:
Address:
City:
State:
Zip:

After filling out your information above, simply indicate the purpose for the payment, enter the amount of the payment, and click the "Click Here to Go to Cart" button to enter your credit card information. Your credit card information is entered on PayPal's secure checkout page.

Payment Information
Please tell us the purpose of this payment: Therapy Session, Book, Workshop, etc...
Payment Purpose:
Amount: