Keith Miller Counseling, LLC

Keith Miller Counseling, LLC

Credit Card Bill Payment Authorization Form
Please fill out all fields below and sign form to submit your payment.

After submitting this form, your card will be processed automatically to charge the amount you specify on the form. The charge may be visible (pending) on your credit card statement immediately, but may not post for 1-4 days after submitting.

This form only needs to be submitted once for any new form of payment, and our system will charge future sessions, using this payment source, after each session (and typically between 1-4 days after your session).
Please select your therapist's name:
Cardholder's Full Name*

First NameLast Name
Full name of other attending therapy*
(Type NONE if not applicable)
Full name of person attending therapy (if different from cardholder) or if conjoint therapy please add your partner's full name.

Same as cardholderOther
Credit/Debit Card Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
E-mail*
Services rendered: Psychotherapy

Total Due*

USDRefer to your clinician or clinician's invoice to enter the fee that is due.

Recurring Authorization*

I agree to the recurring authorization of this card for future services rendered. Contact your clinician to revoke or change your payment method at any time.
Late cancellation and no-show charges*

I understand I may be charged for unattended or canceled appointments based on my written agreement with my clinician which may authorize the full session charge for cancellations either within 24 or 48 hours notice. Refer to your signed copy of your therapist's client/clinician agreement for the specific terms and speak with your clinician if you have any questions.
Enter the message as it's shown*
With my signature, I agree to pay according to my Card Issuer Agreement.

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