Credit Card Authorization

We are here to help you! Call us: 856-547-1107

Ready to get help? Our Counselors are ready to talk.
Teletherapy available upon request.

I give my permission for O’Leary Counseling to keep the following card on file for the purpose of charging counseling services as outlined in my client services contract.

You will be informed before a charge is made and a receipt will be given upon request.

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MasterCard Visa Discover Other

Is this a HAS or FSA card?

HAS FSA No

If other, please specifiy

First Name

Last Name

Address

E-mail

Client Name

Card Number

CCV

Expiration Date

Reason and amount to be charged: Deductibles and copays (if applicable). Late Cancellation or No Show $61.00 ($60.00 cancellation fee + $1.00 CC processing fee). Late Cancellation for a group session will incur a charge of $41.00.

I am choosing to leave a deposit (initial)

By signing this form I acknowledge the charges described hereon and assume full responsibility for said charges and agree to honor and abide by the terms of payment.

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Date

We provide a healthy environment uniquely suited to support your growth and healing.

630 Clements Bridge Rd Barrington, New Jersey 08007

Info@olearycounseling.com

856-547-1107