Credit Card Authorization Form

Please complete the following information. This form will be securely stored in your clinical file and may be updated upon request at any time.

In case of late cancellations, no shows for scheduled sessions, or if a check is returned unpaid, you will be charged the full session fee ($100.00). An addistional $35 is assessed for returned checks.

Full Name *

I, full name, am authorizing Lea Lockwood, Ph.D., LICSW to use my credit card information to charge my credit card in the event that I do not notify her of my inability to attend a scheduled therapy appointment, do not cancel my appointment at least 24 hours in advance, or a check is returned for any reason as agreed to in the Financial Arrangement policies stated in the signed Client Consent and Important information form.

Card type *

Visa

MasterCard

Card # *

Expiration Date *

Name as printed on card *

Verification/Security Code (3 digit code on back of card by signature line) *

Billing Address *

City *

State *

Zip *

Name (as you would sign) *

Date *

By signing below, I am authorizing Lea Lockwood, Ph.D., LICSW to charge for scheduled appointments.

Name (as you would sign) *

Date *