To make a gift to the MGH Center for Women’s Mental Health, please print this page and mail to:

The Center for Women’s Mental Health
c/o Dr. Lee S. Cohen, 185 Cambridge Street, CPZN 2256
Boston, MA 02114

__ Enclosed is a check made payable to Massachusetts General Hospital

__ Please charge my credit card

Amount: $__________

Credit Card Type ________________

Credit Card Number: _______________________

Expiration Date: Month _____ Year_____

__ In addition to my/our gift, a matching gift form is enclosed for (company name): __________________________________________________________________

__ I/We have requested this gift be made through the _________________________ Foundation.

__ I/We pledge this gift in honor of ____________________________________________.

__ I/We wish this gift to remain anonymous.

Contact Name(s): _____________________________________________________________

Street Address: _______________________________________________________________

City/Town, State, and Zip: ________________________________________________________

Home Telephone: ____________

Work Telephone: ____________

Email: _____________________

Signature(s): ________________________________________________

Date: _____________