California Clinic for Anxiety Disorders Annie Zadori, Psy.D License number: PSY 32733 Patient Name: First CREDIT CARD AUTHORIZATIONThis is to authorize Annie Zadori, Psy.D to charge the following fee to my credit card for the duration of my treatment with each time I have a psychotherapy session. Initial Psychological Evaluation: $850 Each session of 53 minutes: $200 - $300 Each session of 90 minutes: $275- $375 Check one:American Express First Visa First MasterCard First Credit Card Number:Expiration date: MM slash DD slash YYYY Name as appears on the card: Card Verification Value (CVV): Billing address and Zip code: Patient or Financial Responsible Parent/Spouse Signature:Date: MM slash DD slash YYYY
