By selecting the box and signing below, I certify that the above information is true and that I am an authorized user on the credit card/debt account above. I authorize Integral Mental Health Counseling, PLLC to keep my credit card information on file and charge the above fees automatically and on an ongoing basis until or unless I cancel these automatic payments in writing. I understand that I am responsible for notifying Integral Mental Health Counseling, PLLC if my credit/debit card information needs to be updated. Integral Mental Health Counseling, PLLC agrees to ONLY charge for services rendered or for appointments not cancelled 24 hours in advance. I understand that if I wish to cancel an appointment I will need to speak with an employee of Integral Mental Health Counseling or leave a recorded voice message.
