Credit Card Payment Form LinkedInThis field is for validation purposes and should be left unchanged.I authorize Jonah Green and Associates, LLC to charge this credit card for each service, unless otherwise specified. Beginning August 1, 2020, credit card charges will include a 3% processing fee.Card Holder InformationPatient Name*Phone*Card Information*Please SelectMasterCard (16 digits)Visa (13 or 16 digits)Discover (16 digits)Card #*Expiration Date*House Number*Zip Code*3-Digit Code*Cardholder Name*Cardholder Signature*Date* MM slash DD slash YYYY Email* Therapist*Please SelectJonah Green, LCSW-CAron Carlson, LCSW-CHeidi Cohen, LCSW-C, CGABSDani Delgado, LGPCKatherine Doyle, LMSWChris Erb, LCMFTJennifer Firestone, LCSW-CShannon Golub, LMSWShannon Harris, LMSW, MBA, RYT-200Lucy Kaminska-Silver, LCSW-CYasmin Meyers, LCSW-CLori Rothfeld, JD, LMSWFarah Shirazi, LCSW-CKerrith Solomon, Intern TherapistEmily Varlas, LMSW, MS Ed.CAPTCHA Updated: 7/10/2020