Credit Card Authorization Agreement

CANCELLATION AND SERVICES – REQUIRED FOR ALL CLIENTS

I agree to pay the full session date for an individual, couple, or family therapy for any missed/cancelled appointments. If I have not cancelled with 24 hours' notice the schedule appointment date in accordance with the cancellation policy (stated in the Therapist-Client Services Agreement). Please note that the credit card payments, including those used for no-show appointments, incur a small processing fee. *

Returned credit card/check fee of the initial chare amount and the additional fee. *

I agree that telephone contact or other counseling/consultations services (stated in the Therapist-Client Services Agreement) in access of 15 minutes other than that associated with normal scheduling services will be billed at the prorated 45 minute session rate per 10 minutes increments.) *

Credit Care Type *

Credit Card Number *

Security Code *

Expiration Date *

Name as Printed on Card *

Zip Code: *

All Credit Card payments incur the following processing fee (for striped cards: 2.75%/transactions; for manually entered card information: 3.5%+14cents/transition)

(Optional) Please charge my card on file for each counseling session rendered until I notify of a change in this payment option/method. Please note that credit card payments incur a small processing fee. *

The above confidential information will be kept on file in a secured and locked location. By signing this agreement I am authorizing, Tanya Thomas Therapy, to charge the above credit card account for the above professional services rendered to my, my spouse/partner or on behalf of other family members. This information is complete and correct. I agree ti update any information regarding the above account.

Responsible Party for Services (print) *

Date *

Please type your name below to agree you are willing to share the details input into this form with Tanya Thomas Therapy *

Disclaimer: All credit card information will be maintained and locked in a HIPPA complaint location. This information will only be accessed or used if a no-show service is required. This document will be destroyed by shredding once all therapy services are completed terminated.

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