Dr. Jennifer Rubolino, LMHC
5300 W. Atlantic Ave., Suite 408
Delray Beach, FL 33484

Fee Agreement

I understand that I am solely responsible for payment in full at the time of service. I understand that a therapy session is defined as a 50-minute session. I understand that appointments cancelled within 24 hours of the scheduled time will be billed at the full private session fee. Missed sessions will be charged to the credit card I have provided below. I understand that payments may be made using the credit card on file, as well as through Zelle, Venmo, or cash. A credit card will be required to be kept on file for all clients. If Zelle or Venmo is used for payment, the credit card on file will only be charged if payment is not received within 48 hours of a session being held, or in the event of a no-show or a cancellation made outside of the 24-hour policy. I understand that a 3.5% processing fee applies for credit card payments. Should I wish to avoid this processing fee, I will notify Dr. Rubolino and submit payment via Zelle, Venmo, or cash. *

Yes, I understand I am responsible for payment.

Name *

First

Last

Method of Payment

Zelle
Venmo
Cash
Credit Card

Zelle/Venmo Username (if using)

Credit Card Number *

Please note: A credit card is required to be kept on file for all clients, but it will not be charged unless necessary. If you are using Zelle or Venmo for payment, this card will only be charged if payment is not received within 48 hours of your session, or in the event of a no-show or late cancellation (less than 24 hours). A 3.5% processing fee applies to all credit card payments.

Expiration Date *

Security Code *

Zip Code *