Client Payment Information - Lexthera Psychotherapy

Mike Lubofsky, Licensed Psychotherapist and Attorney
Psychotherapy for Individuals and Couples

Phone:
415-508-6263

Request Appointment

Client Payment Information

Please provide your payment information below so that we can process your payment on Square following our online session.

Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Email*
Session Fee
Session Fee (per 50 minute session)*
Credit Card Information
Credit Card Number*
Card Type*
Expiration Month*
Expiration Year*
CVV Number*