Card on File Authorization

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I hereby authorize Parsons Counseling LLC to charge the following card for any payment due for individual & group counseling sessions for the listed client. I understand that this card will be charged after the client attends a session. I understand the amount charged will be based on my insurance benefits or the cash rate option agreed upon in the client’s chart.

电子邮件地址 *

Client's Name *

Client's Date of Birth (you may type the date in MM/DD/YYYY format or click the calendar to find it) *

年

月

日

Card Number: *

Cardholder's Name as it Appears on Card: *

Expiration Date as it Appears on Card: *

3 Digit Security Code on back of Card: *

Card Holder Billing Street Address: *

Zip Code for the Card: *

Electronic Signature: *

*Please type your name in order to authorize this form. Your typed name will be your electronic signature.

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