Credit Card Authorization Form
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 *
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: *
MM
/
DD
/
YYYY
Signature *
Type your name here for your consent to use this information
Submit
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