CREDIT CARD AUTHORIZATION FOR PSYCHOLOGICAL SERVICES RENDERED

Please read and initial consent next to each section below

I authorize Edwards Psychological Associates to keep my credit card on file for any future transactions until I request a cancellation. I will provide current card information at or before my first appointment. I understand that the terms of this authorization will remain in effect until I request that they be terminated. I acknowledge that I am responsible for making this request in writing.

This recurring charge is to cover the cost of clinical services provided by Edwards Psychological Associates.

*$300-$425 - Initial Assessment

*$170-$290 - Individual Sessions (and pro-rated phone calls)

* Rate depends on individual therapist. This information has been discussed prior to scheduling and can be found on therapist bio pages on the website.

I understand that this card will be charged for other clinical services including but not limited to phone calls, documentation letters, school consultation or other necessary consultation.

I understand that rates typically increase annually in January.

I understand that this card will be charged in the event of late cancellations (less than 24 hours business day notice) or no shows.

I understand that I will be emailed a monthly billing statement to the email address included in this contract unless I provide an alternate email address or request a different plan for billing statements.