Payments and Insurance — Short Hills Counseling PC

In order to make a payment, please fill out the information to the right.

Client's Name

First Name

Last Name

Client's Phone Number

(###)

###

####

Therapist's Name

First Name

Last Name

Invoice #

Payment Amount

Name on Credit Card

First Name

Last Name

Credit Card Number

Exp Date

YYYY

CVV

Client Zip Code