Rebecca Elman, Ph.D., P.A.
Licensed Psychologist

Gifted Testing Policies and Card Authorization

Private review — fictional information only

Use stripe-test@example.com and Test Parent. Card: 4242 4242 4242 4242; expiration: 12/30; CVC: 123; ZIP: 33431. No real payment is made. When email testing is enabled, both sample emails go only to the approved test mailbox.

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Child’s name

Child’s first name

Child’s last name

Email for your confirmation

Mobile Number

Appointment confirmations and reminders will be sent to this number.

I agree to the policies above and authorize card storage and cancellation-fee charges as described.

Patient or Parent/Guardian’s Electronic Signature

First name

Last name

Date

By selecting “Sign and Continue to Secure Card Setup,” you electronically sign the policies and card authorization above.

Enter your card details on Stripe’s secure page after signing. No payment is collected during card setup.

Download signed policies and authorization

Read the current policies

Continue with your remaining forms

If you have not already done so, complete the Background Information and School Communication forms. Signing the policies does not submit those forms.

Return to your original Gifted Testing Forms tab to continue with any answers you have already entered. You may close this policy tab.

If the Gifted Testing Forms page is no longer open, open Gifted Testing Forms.

1875 NW Corporate Boulevard, Suite 100 · Boca Raton, FL 33431
561-470-8660 · rebeccaelman@gmail.com