Invoice Payment

Amount Due*

USDInvoice Amount

Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby authorize Creekside Counseling Group to charge my credit card for the amount listed on the invoice and confirm that the information for the credit card and billing address is complete and accurate.
This authorization is for a one-time payment only and your payment information will not be stored. If you would like your payments to be processed automatically following each appointment, please either contact us at (810) 771-4074 or complete the Payment Authorization Form.
Should be Empty: