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.