Credit Card Form

Please complete all fields. You may cancel this authorization at any time by contacting us at [email protected] or your therapist. This authorization will remain in effect until cancelled. All information is encrypted for privacy purposes.

Name *

First

Last

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Credit Card Number *

Secret Code (CVVS)

Expiration Date

Name of Client *

If you are putting in your information to place on file or pay someone else's bill, input their name in the space above.

Signature

Clear Signature

I acknowledge that by submitting this form I am authorizing Virginia Counseling Services to charge my credit card for agreed upon services. I understand that my information will be saved on file for future transactions on my account.