Credit Card Authorization

  • If I have questions about these charges, I agree to contact Associates in Psychotherapy ([email protected]). I agree that I will not pursue a refund directly through my credit/debit card company, bank, or financial institution. If any of my actions yield a chargeback for any reason, I agree to pay any and all penalty fee(s) incurred by Associates in Psychotherapy.

    I give Associates in Psychotherapy permission to charge my credit card for the balance of fees not paid by my insurance company. We charge all copayments at time of session and balance (co-insurance, deductibles, and services not covered by your insurance) after receipt of Explanation of Benefits.