This page only needs to be completed if you are making payment for the Psychotherapy Program. If you did not enter the faculty member’s name and dates of service when making payment, please do so below. Otherwise, you can disregard this form.
This page only needs to be completed if you are making payment for the Psychotherapy Program. If you did not enter the faculty member’s name and dates of service when making payment, please do so below. Otherwise, you can disregard this form.