Client’s Name:

Email:

Type of Card:
VISAAMEXMASTERCARDDISCOVER

Card Numbers:

Cardholder’s Name (as on card):

Card numbers:

Expiration Date: /

CVV: Zip Code:

I authorize Mental Health Services of Maryland, LLC to process my credit card for all services, fees, and appointments related to my therapy sessions. I understand that a cancellation fee of $50 will be charged if an appointment is not canceled at least 24 hours in advance. I confirm that the credit card details provided above are accurate to the best of my knowledge. In the event of inaccuracies or fraudulent activity, or if my payment is declined, I acknowledge my responsibility for the full amount owed, including any interest or additional costs incurred due to denial.

Print Client’s Name:

Email:

Client’s Signature:

Date: