This form authorizes Brian Whitley to charge the credit card, debit card, or bank account listed below for counseling services. Brian Whitley’s cancellation policy states that sessions which are missed or cancelled within 24 hours of the scheduled appointment time are billed for the scheduled, full session rate. The card holder or account owner listed below will be responsible for all charges related to missed appointments or late cancellations.

Checks, cash, electronic checks, Zelle, and credit cards (Visa, MasterCard, Discover) are accepted for payment. There is a 3% convenience fee for using a credit or debit card. There is no fee for using Zelle, checks, cash, or electronic checks as payment.

If you would like to use a credit card, debit card, or electronic check as payment, please enter either your credit or debit card or bank account information in the form below: