• Payment Information

  • I ­­­­­­­­_________***input name below***___________________understand that I am financially responsible for the services I receive from Carmen Gehrke, LMHC with Longwood Therapy LLC, that payment is expected at the time of service, and the fees are as follow.

    $135.00 per 50-minute individual session

    $150.00 per 50-minute couples therapy session

    If due to hardship, I am not able to pay the full amount, I will address this situation with Carmen Gehrke.

    Payment is accepted in the form of cash, debit or credit card, or check.

    Delinquent accounts will be sent to a collection agency and will include a $25 collection fee. Credit cards charges that don’t go through will be subject to a $50 fee. In this cases, the only information that will be released is your name, the services provided, and the amount due.

    I authorize Carmen Gehrke, LMHC with Longwood Therapy LLC, to save the credit card information bellow and charge it when I breach the Cancellation policy.

  • Credit Card Information

  • I authorize Carmen Gehrke, LMHC with Longwood Therapy LLC to save the credit card information listed in this form, to keep my signature on file, and to charge my credit card for recurring charges (ongoing treatment) as per amounts stated in the signed Polices and Fees statement.

     

    I have read and understand Carmen Gehrke, LMHC fees for service and cancellation policy.

     

    I agree to have any current and future unpaid fees charged to the card listed above.