Payment authorization

For when the practice card reader is in use. Do not type a full card number into this website. Therapy amounts are charged only after they were named.

This form waits until the card reader on your phone is in use. It does not store a card on the website and does not invent a session rate.

Card reader authorization — paper only

R.O.S.E. does not process cards on this website. When the practice card reader on J'Vohnne's phone is in use, this paper lets a family authorize charges for fees that were already named. Do not type a full card number, expiration date, or security code into this website. Write those only on a printed page you hand over, or enter them on the reader.

Client name *Name of cardholder *I authorize (when the reader is used)

Charges for brief consultation at $25 per 15 minutes when that visit happenedA $25 late cancel / no-show fee unless waivedTherapy or IEP amounts only after those amounts were named to meI understand this is not a stored card on the website and not a health-plan claim

Card brand and last four (optional; never the full number)Cardholder signature *Date *

Drafts stay on this device only. Printing creates a PDF through your browser. Emailing opens your mail app with a text summary. These templates support care and documentation; they are not a substitute for legal review of privacy or consent language.

Every journey begins with hope.
Every bloom begins with R.O.S.E.

Every bloom begins with R.O.S.E.