Credit Card Authorization Form

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Please complete the following information. This form will be securely stored in your clinical file and may be updated upon request at any time.
In case of late cancellations and/or no shows for scheduled sessions, your credit card will be charged the full session fee of $125

Your Name *

Please use my credit card for payment of services.

I also authorize Pamela Hollings, LCSW to charge my credit card in the event that I do not notify her of my inability to attend a scheduled therapy appointment, do not cancel my appointment at least 24 hours in advance, a check is returned for any reason or there is an outstanding balance after 30 days.

Type of Card *

VISA

MASTERCARD

Expiration Date

Month *

Year *

Name on Card *

Card Number *

Verification/Security Code *

(3 digit code on back of card by signature line)

Billing Address: *

City: *

State: *

Zip: *

Date: *

YYYY

Signature *

Type your name here for your consent to use this information

Submit

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