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:
 
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 * 🛈
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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