Credit Card Payment Consent

Please complete the following form prior to your first appointment with us. If you have any questions, please call us at 859.554.0740.

Card Holder's Information
Card Holders Full Name*
First Last
Phone*
Email*
Billing Address*
Street Address Address Line 2 City State ZIP Code
Credit Card Information Provided*
I have called Willow Creek Counseling Center, LLC and provided my credit card information for billing at 859.554.0740.
- Yes
Signature Agreement
I authorize Willow Creek Counseling, LLC to charge my credit/debit/health account card for professional services 24 hours before our scheduled appointment. If I do not cancel before 24 hours, I recognize that Willow Creek Counseling, LLC will charge my card as a late cancellation or no show if I do not show up for the appointment. I will be billed for the full session charge.

I verify that my credit card information, provided above, is accurate to the best of my knowledge. If this information is incorrect or fraudulent or if my payment is declined, I understand that I am responsible for the entire amount owed and any interest or additional costs incurred if denied. I also understand by signing and initialing this form that if no payment has been made by me, my balance will go to collections if another alternative payment is not made within sixty days.
Card Holder's Signature*
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Card Holder's Information