Dr. Jennifer Rubolino, LMHC5300 W. Atlantic Ave., Suite 408Delray Beach, FL 33484 Fee Agreement Download & Print Please enable JavaScript in your browser to complete this form.I understand I am solely responsible for payment in full at the time of service. I understand that appointments cancelled within 24 hours of the scheduled time will be billed at the full private session fee. Missed sessions will be charged to the credit card I have provided below. A therapy session is defined as a 50-minute session. *Yes, I understand I am responsible for payment.Name *FirstLastCredit Card Number *Expiration Date *Security Code *Zip Code *Submit
