We use Square to securely store your payment information and charge your card. HSA and FSA cards are now accepted.
Child's first and last name (or name of Adult receiving services):*
Name of person filling out form:*
Relationship to client:*
Cardholder Name (as shown on card):*
Billing street address:*
Credit card number:*
Credit Card Security code:*
I hereby authorize Gold Speech, Inc. to charge the indicated credit card. I am aware of the company policy requiring cancellation by 7:00 a.m., if not sooner, the day of the scheduled session, to avoid the session charge. I am aware that I cannot receive reimbursement from my medical insurance for late cancellation fees of missed sessions. I agree that this is either a recurring or one-time charge that will be made, and I will not dispute it in the future. To terminate the recurring billing process, I must cancel in writing, preferably with 2 weeks notice.
I agree to the terms Type your name as your electronic signature:*
To be considered for services, please complete an intake form for your child or yourself.
Call: (650) 669-8539
Serving homes in Palo Alto, Los Altos, Mountain View, Sunnyvale, Santa Clara and parts of Cupertino and San Jose, California
Thank you for your submission!