Credit Card Permission Form

All fields in this form are required. To save time, please read the form first and make sure you have all of the required information before you begin.

CREDIT CARD PERMIISSION

I hereby authorize Dr. Monya Cohen, Psy. D. to keep this form on file, and charge my credit card identified herein for any of the following: initial evaluations; psychotherapy sessions; other related services; appointments cancelled per the no-show policy; and payments that are 30 days past due.

First Name

Last Name

Type of Card

Visa

Master Card

Discover

American Express

Card Number

Expiration Date

CVV (3-digit security code)

Billing Address

AUTHORIZATION AND CONSENT I understand the terms of this form and agree that it is valid for five (5) years unless treatment is terminated or I cancel this authorization through written notice to Dr. Monya Cohen, Psy. D. By typing my name in the box below and clicking "I Consent," I provide my electronic signature and agreement to the terms above.

First Name

Last Name