Credit Card Authorization – COUPLES COUNSELING

credit card authorization form

Credit Card Authorization

First Name on CC

Last Name on CC

Phone/Mobile

Credit Card Billing Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Credit Carad Number

Expiration Date

Security Code (3 or 4 digits)

I authorize Couples TLC Counseling, Inc. to charge my credit card for mental health services.

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