Feeling Good Psychotherapy | Secure Credit Card Form

Secure Credit Card Form

Feeling Good Psychotherapy requires a credit card on file, regardless of how clients plan to pay for their sessions. This credit card will be charged the late cancel fee for any session missed or not cancelled at least 24 hours in advance (48 hours for Monday sessions).

Please enter the client's name and your credit card information, followed by your electronic signature.

Are you completing this form for a new or existing client? *

New

Existing

Client's Name *

Is the client also the credit card holder? *

Yes

Credit Card Holder's Name *

Credit Card Number *

Credit Card Expiration Date (MM/YY) *

Credit Card Security (CVV) Code * 🛈

Credit Card Billing Zip Code *

By signing electronically below:

This authorization will remain in effect until I notify Feeling Good Psychotherapy that I wish to change my method of payment to a different credit card. If the card on file is declined I agree to provide a new credit card as soon as possible. I understand that as part of the agreement, I must have a working credit card on file at all times to maintain a zero balance for copays and fees owed. If I have an unpaid balance I understand my upcoming appointment may be rescheduled.

If I need to cancel an session, I will provide 24 hour notice (48 hours for Monday sessions), or Feeling Good Psychotherapy will charge a cancellation fee of $85.00. Insurance will not cover payments for missed visits.

This authorization will remain in effect until I notify Feeling Good Psychotherapy that I do not want future charges to be authorized.

Client's Signature * 🛈

clear

Dated *

Credit Card Holder's Signature * 🛈

clear

Dated *