The Feeling Good Center
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. You may call us at (914) 533-4950 with any questions.
Are you completing this form for a new or existing client? *
Is the client also the credit card holder? *
By signing electronically below, I certify that I am an authorized user of this credit card and authorize Feeling Good Psychotherapy to charge the credit card listed above for my office visits. My card will be charged at the end of each visit or within 24 hours of my visit. I understand that refunds are not possible for visits that have been completed. If my insurance company issues checks to me for visits with Feeling Good Psychotherapy, I will sign them over to Feeling Good Psychotherapy LCSW PLLC and bring them to my therapist within 2 weeks from the date of issue, or my card may be charged for the amount of the check.
 
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 * 🛈
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Credit Card Holder's Signature * 🛈
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Feeling Good Psychotherapy LCSW PLLC
235 Main Street • Suite 520 • White Plains, NY 10601
380 Lexington Avenue • 17th Floor • New York, NY 10168
160 Broadway • Suite 1204 • New York, NY 10038
feelinggoodcenter.com
(914) 533-4950