A - Applicant Information

Name

First Name

Last Name

Email Address

Client Information

If Recipient of Treatment or Evaluation is Different from Payee Please Provide the Following Information:

Client Name

First Name

Last Name

B - Billing Information

Please complete the following information if you have chosen to use credit/debit card method to pay for a co-payment or total cost of services

Name

As it Appears on Credit / Debit Card

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Credit Card Authorization

Provider

Visa

MasterCard

Discover Card

Credit-Debit Card Number

Card Expiration Date

YYYY

Security Code

Authorization

I authorize Dr. James D. Wellman Psy. D. or its authorized credit/debit card transaction agent(s) to bill my credit/debit card account indicated above for assessment, therapy or consultation.

Signature by Name

Date

YYYY