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Supervision Payment Form Financial Assistance

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This form is for clients of AHE student practitioners who have requested financial assistance.

Contact Information
Your Student Practitioner's Name*
First Last
Your Name*
First Last
Consultation Date
MM slash DD slash YYYY
Your Email*
Your Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Are you the one needing care?*
- Yes
- No
Your relationship to the client:*
Client Name*
First Last
What type of consultation are you paying for?*
- AHE Supervised Student Practitioner Chronic Initial Consultation
- AHE Supervised Student Practitioner Chronic Follow-up Consultation
Payment Information
Consultation Fee*
You are using this form because you have requested financial assistance. Please enter the amount agreed upon for your consultation.

Credit Card*

Cardholder Name

Card Details

Total
$0.00
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