Innovative Psychology Counseling Services

Credit Card Authorization

This form is for you to supply Innovative Psychology Counseling Services with credit card information to keep on file for the payment of all services and fees. A new form must be completed for each card kept on file. (We do not accept Discover Card.)

Name on Card, Credit Card Number, Expiration Date, and CVV Code *

Please list anyone other than the cardholder that is authorized to use this credit card. Name and Date.

Cardholder's Signature *

I hereby authorize Innovative Psychology Counseling Services to charge the credit card listed above for the payment of all services and fees. This credit card will be kept on file and will remain in effect until the expiration of the credit card account. Clients may revoke this credit card on file by submitting a written request to the address at the top of this form. A new form must be submitted if any information such as credit card expirations or authorized users is amended. Clients agree to pay the cost for any returned or challenged payments.

Client Name and Date *

Client Signature *