Credit Card Authorization Form Sound Christian Counseling Inc. 4800 S. 188th St. Suite 260 SeaTac, WA 98188 Ph: 206-762-3007 - Fax: 206-243-9583Dear: Sound Christian Counseling Client, Our office policy since November 2010, is to obtain and hold a credit card authorization on file for each client. We value you as a client and make it a priority to be available for your scheduled appointment. Your authorization allows us to be compensated for the time we have reserved for you when you are unable to keep your appointment. This will allow us to charge your credit card for unpaid balances, no shows, missed appointments, and cancellation of any scheduled appointments with less than a 24-hour notice. Please fill out the attached form prior to your scheduled appointment. Thank you for allowing us to serve you. Veronica Rasmussen, LICSW Sound Christian Counseling, Inc., 4800 S. 188thSt., Suite 260 SeaTac, WA 98188 (206) 762-3007 www.soundchristiancounseling.comCredit Card (circle one): Visa MasterCard DiscoverName as it appears on card Credit Card Number Expiration Month(MM) Expiration Year(YY) Number3 Digit Code (From Back of Card)Address credit card statements are mailed to (including zip code)Phone Number Associated With Card BillingClient Name I,Name authorize Sound Christian Counseling, Inc., to charge my credit card for psychotherapy sessions, appointment “no shows” and cancellations made in less than 24-hours before my scheduled appointment. I understand that I will be held responsible for any charges or fees if authorization is declined, and I will advise Sound Christian Counseling, Inc. immediately if I close or update this accountSignatureDate MM slash DD slash YYYY CAPTCHA
