Credit Card Payment Form 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-CRicardo Andrews, MA, LGPCRachel Boxman, LMSWAron 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-CJamie Rosen, LMSWLori Rothfeld, JD, LMSWFarah Shirazi, LMSWCAPTCHACommentsThis field is for validation purposes and should be left unchanged. Updated: 7/10/2020