Credit Card Payment Form

I authorize Tracy Riley Counseling to charge my credit/debit card for professional services as follows:

I understand that my credit card will ONLY be charged if I do not keep my appointment, or if I fail to cancel the appointment prior to the 24 hour cancellation window.  Otherwise, my card will not be charged.  I understand that my information will be kept in a cloud based billing system.    

I understand that my credit card will be charged for today’s appointment only, if needed, for co-pay, deductible, or full session fee that has already been discussed with me previously.

I understand that if my card is declined, that I remain responsible for the charges owed.  I understand that Tracy Riley Counseling will make every effort to collect the charges owed, up to and including utilizing a third party collection agency, and reporting negatively on my credit bureau file.

If I have questions about these charges, I agree to contact my provider at Tracy Riley Counseling.  

I agree that I will not pursue a refund directly through my credit/debit card company, bank, or financial institution. If any of my actions yield a chargeback for any reason, I agree to pay any and all penalty fee(s) incurred by my provider.