By your electronic signature of this form, you authorize charges to your credit card through Stripe via RefocusCounseling for services rendered. These charges will appear on your bank/credit card statement as [RefocusCounseling]. You have the right to request a paper copy of this document.

I authorize RefocusCounseling to charge my credit card through Stripe. I also agree that my credit card can be charged for any session that is not cancelled at least 24 hours prior to the scheduled session.

I understand that this authorization will remain in effect until I cancel it in writing or verbally, and I agree to notify Refocus Counseling in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.