Credit Card Authorization

Attention: PEG KIRKVOLD | Accounts Manager | (952-934-4856)

Faithful & True prefers not to bill for individual or group therapy sessions. Payment should be made at the time of service OR you may keep your credit card number on file for our Accounts Manager to charge automatically. Your charges will be shown as “Faithful & True Ministries” and will appear on your card approximately 3-7 days following your actual individual or group session. If you would like to pay by credit card for your session(s), please fill out the form below and submit it to us.

All information is confidential and will be used only when you have authorized us to do so. If you would like us to keep your credit card number on file to automatically charge after each session you attend, please select the appropriate box below.

If your credit card number changes or expires, please call me at the number above to update your account.

Name

First Name Last Name

E-mail *

example@example.com

Phone Number *

Download the credit card authorization form. You may digitally sign or print and sign with ink. When the document is signed, please upload below.

-> Download Authorization Form

Please upload your signed authorization. *

Signature *

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