Credit Card Authorization
In order to hold your appointment with Amy Sharma or Geoffrey Fong, we ask that you place a credit card on file. In the case that an appointment is cancelled outside of our policy (see below), you will be charged for the cost of the appointment ($300 for intake appointments, $150 for follow up appointments).

This form is secure and submits your payment information directly to an encrypted database.

Email address *
Client Name *
Your answer
Name on Credit Card *
Your answer
Credit Card Number *
Your answer
Your answer
Credit Card Expiration Month *
Credit Card Expiration Year *
Billing Zip Code *
Your answer
By Typing Your Name You Agree the Above Information is Correct *
Your answer
Summary of Cancellation Policy
Except in the case of an acute emergency or illness, we require a two business days notice for any cancellation; otherwise, your account will be charged for the visit. If our office is closed, leave a message on our office voice mail, the Valant portal, or send us an email to inform us of your cancellation.


We have a two-day, two-tier cancellation notice policy.

If you need to cancel or reschedule with less than 48 hours notice, you will be charged $50.

If you contact us within 24 hours of your appointment, you will charged your full appointment fee ($300 for intake appointments and $150 for follow up appointments)

Never submit passwords through Google Forms.
This form was created inside of Puget Sound Psychotherapy & Psychiatry, PS. Report Abuse - Terms of Service