Healing Psychotherapy Practices of Georgia, LLC
3750 Palladian Village Dr., Suite 320 Marietta, GA 30066 Tel: 770) 792-0079
Credit Card Authorization
*when paying for another adult's services (anyone over 18)*
I am authorizing Healing Psychotherapy Practices of Georgia, LLC to charge my credit card for the services of this client
THERE IS NO PAPER COPY OF THIS DOCUMENT. THIS IS UPLOADED TO OUR HIPAA COMPLIANT ELECTRONIC HEALTH RECORD.