Credit Card Authorization Form

Payment Policy and Consent for Weekly Credit Card Charges

To ensure smooth and timely payment for therapy services, our practice requires a credit card to be kept on file, even if payments will be submitted through the Step Up Scholarship program. Your credit card information will be securely stored and processed by a reputable third-party payment processor that complies with industry-standard data protection and encryption practices. Our practice does not store or have direct access to your full credit card details.

Policy Overview:

• All clients are required to keep an active credit card on file.
• Credit cards will be charged at the end of each week for services rendered and any outstanding balance on the account.
• A receipt will be emailed for each transaction.
• If a charge is declined, you will be notified, and payment must be resolved before the next scheduled session.
• It is the parent/guardian’s responsibility to notify our office if the credit card on file has expired, or if they wish to change their payment method.

I, {cardholderName}, as a cardholder, understand these terms and hereby authorize Therapy West 2 to automatically charge my card each week for services provided and for any outstanding balance on the account. I confirm that the information for the credit card and billing address is complete and accurate.