Counseling on Burnside
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Counseling Visit Summary
Today's date
Date you had session with counselor
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Order Amount
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$160 New Patient Charge
$125 Regular Fee
$60 Hardship Fee
$40 Co-pay
$30 Co-pay
$25 Co-pay
$20 Co-pay
$15 Co-pay
$10 Co-pay
Counselor Seen:
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-- Select One --
Joe Alexander, LCSW
Ruth Berger, LCSW
Angie Johnson, LCSW
Jen Warren, LCSW
Claudia James, LCSW
Franny Thompson, LCSW
Shayna Diaz, LPC
Maureen McCormick, LCSW
Additional Information
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Card Expiration Date
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Billing Information
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Last Name
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