Credit Card Authorization Form

Please complete the following information.  This form will be securely stored in your clinical file and may updated upon request at any time.

In case of late cancellations and/or no-shows for scheduled sessions, your credit card will be charged the session fee of $150 for a 45 minute session and $300 for a 90 minute session.


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Your Name *
Please use my credit card for payment of services.
I also authorize Pamela Hollings, LCSW, to charge my credit card in the event that I do not notify her of my ability to attend a scheduled therapy appointment or do not cancel my appointment at least 24 hours in advance.

Type of Card *
Expiration Date
Month *
Year *
Name on Card *
Card Number *
Verification/Security Code *
(3 digit code on back of card by signature line)
Billing Address: *
City: *
State: *
Zip: *
Date: *
MM
/
DD
/
YYYY
Signature *
Type your name here for your consent to use this information
Submit
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