CREDIT CARD AUTHORIZATION FORM

I authorize Choosing Change LLC to charge my credit card for therapy sessions provided by my therapist at the predetermined rate per 50 minute session. If I decide, that I need a session to be longer than 50 minutes, the charge to my credit card will reflect the additional time. In addition, I consent for Choosing Change LLC to charge my credit card the same rate for cancellations less than 48 hours from the scheduled session time, per the practice's cancellation policy, as well as any missed sessions.

Additionally, we value the opportunity to collaborate with our client's treatment team. However, when we are asked to do any of the following and it surpasses 15 minutes of your therapist's time outside of session, the time will result in a charge that reflects your session fee:

1. Collaboration with outside treatment team professionals such as psychiatrist, school officials, primary care doctor, etc.

2. Writing letters for outside professionals such as school officials, court officials, etc.

I understand that my therapist will notify me of these charges when they are made. I guarantee payment for any services rendered made with my credit card, including renewed cards.

 

Important: You must bring your card to the first session, to be stored on file.