Payment Information Form

Please complete this form and click "submit" at the bottom.

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Please enter the payment information of the form of payment you would like to use to pay for your therapy sessions:

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Expiration Date: *

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By your electronic signature of this form, you authorize charges to your card through Stripe for services rendered, and certify that you are an authorized user of this card. You also are stating that you are aware of and accept the office policies and current [as of 2025] fees for services.

This authorization will remain in effect until you notify Dr. Shannon Francom, LMFT-S & Associates of any changes in your account information or termination of this authorization.

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Dr. Shannon Francom, LMFT-Sand Associates

Dr. Shannon Francom, LMFT-S
and Associates