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New Patients
Credit Card Authorization Form
(Check all that apply)
(Required)
$ for all individual, couples, or family counseling sessions
Copay or insurance rate for all attended appointments
$ for any appointment missed or canceled with less than 24 hour notice
Other
Name Printed on Card:
(Required)
First
Last
Credit Card Number:
(Required)
Please enter a number from
8
to
16
.
CVC 3 or 4 Digit Code:
(Required)
Please enter a number from
3
to
4
.
Billing Address Zip Code:
(Required)
ZIP / Postal Code
Consent
(Required)
by clicking here, I understand and I submit my electronic signature
By selecting the box and signing below, I certify that the above information is true and that I am an authorized user on the credit card/debt account above. I authorize Integral Mental Health Counseling, PLLC to keep my credit card information on file and charge the above fees automatically and on an ongoing basis until or unless I cancel these automatic payments in writing. I understand that I am responsible for notifying Integral Mental Health Counseling, PLLC if my credit/debit card information needs to be updated. Integral Mental Health Counseling, PLLC agrees to ONLY charge for services rendered or for appointments not cancelled 24 hours in advance. I understand that if I wish to cancel an appointment I will need to speak with an employee of Integral Mental Health Counseling or leave a recorded voice message.
Date
MM slash DD slash YYYY
Name
(Required)
First
Last
