Credit Card Authorization and Information Form
I authorize Whole Heart Counseling to charge my credit care monthly when remittance bills are sent out. I understand that my full balance will be charged unless otherwise arranged with Noah Simcox.
By entering my name below, I certify that the above information is true and accurate and that I am an authorized user on the credit card/debit account above. I authorize Whole Heart Counseling to keep my credit card information on file and charge the above fees automatically and on an ongoing basis until or unless I cancel these automatic payments in writing. I understand that I am responsible for notifying Whole Heart Counseling if my credit/debit card information needs to be updated. Whole Heart Counseling agrees to ONLY charge for services rendered or for appointments not cancelled with 24 hours in advance.