Child Intake Form (Page 6 of 8) in pdf

Client Name: ___________________________________________________________ Date: ___________________

West Houston Counseling Center, PLLC

Credit Card Authorization

All clients must have a credit card on file to receive services.

Please make no marks or add comments to this page of the document. It is your consent to make payment for services

rendered and your treatment is conditional on your signing this consent form without modification. This form will be

securely stored in your clinical file and may be updated upon request at any time.

In the case that you miss or fail to cancel an appointment within 24 hours of the scheduled time, you will be charged a

$50 fee. If a check is returned unpaid, your credit card will be charged the amount of the check. An additional $35 fee

will be assessed for 1) returned checks, and 2) inaccurately disputed claims/charge backs.

I, _____________________________________________________, hereby authorize West Houston Counseling Center,

PLLC, to bill my credit card at the usual fee for professional services including all of the following:



Appointments and/or copayments that I elect to pay for by credit card



Missed appointments



Telephone, email, and Skype consultations



Appointments that I have cancelled with less than a 24-hour notice



Returned checks



Fees not covered by insurance or insurance payments made to patient rather than provider

Credit Card Type (check one):

____ Visa

____ MasterCard

____ Discover

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: ______________________

By signing below I am authorizing West Houston Counseling Center, PLLC to bill my credit card at the usual fee for

professional services. I will not dispute charges (“charge back”) for sessions I have received or appointments I have

missed according to the above policy.

Signature: ___________________________________________________ Date: ____________________

Print Name: ___________________________________________________________________________

Child Intake Form Page 6