Payment Authorization
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I authorize the Center for Therapy & Counseling Services, LLC, to charge my card below for services provided. I understand that my information will be saved on file for future transactions on my account.
Enter name on credit card below as consent. *
Card number *
Expiration date *
I understand that I may cancel this authorization at any time by contacting us. This authorization will remain in effect until canceled. *
Required
Date *
MM
/
DD
/
YYYY
Client's name (if different from billing name)
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