Client Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

My signature authorizes the charging of my credit card for services rendered. I understand that the card information on this form will be saved in my confidential client chart, and ONLY be charged in the event of a missed or late cancelled appointment for a fee of $75. This agreement will remain in effect until I am discharged from treatment, or I revoke this agreement in writing. *

Yes, I understand.

In the event that I chose to utilize the card below for weekly sessions, I understand that a $3.00 charge will be added to my payment as a convenience fee, and may not be reimbursable by insurance companies. *

Yes, I understand.

Name as it appears on credit / debit card *

First Name

Last Name

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

Alternate Number

(###)

###

####

I will provide my credit/debit card information including the Card Number, Expiration Date, and Security Code over the telephone to ABC Counseling. *

Yes, I agree.

E-Signature *

By signing this consent, you are hereby agreeing to the preceding terms and acknowledgements:

First Name

Last Name