Please complete all fields below. You may cancel this authorization at any time by contacting Northeast Family Services.
Please complete the information below:
I authorize Northeast Family Services to charge my credit card account for charges associated with therapy appointments. I understand my information will be kept on file for future transactions for one year.
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.