Credit Card Authorization

By signing this electronic form, you authorize Elle S Avery Med LPC to charge your credit card (debit card, FSA, HSA) using Stripe, a payment processing platform, via “SimplePractice” for services rendered. You will be charged shortly after the completion of each session. These charges will appear on your bank/credit card statement as
[ELLE AVERY ALLENTOWN].
You have the right to request a paper copy of this document.

I authorize Elle S Avery Med LPC to charge my credit card through Stripe. I also agree that my credit card will be charged $75 for any session that is not cancelled or rescheduled at least 24 hours prior to the scheduled session. In addition, clients will be charged $75 for client “No Shows.” Therapist will wait approximately 10 minutes (from the start of scheduled session time) for client to log-on and start their virtual session. After 10 minutes and client still has not signed on, therapist will log off and will consider the session to be a “No Show.”

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Elle S Avery Med LPC in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions may be linked to Protected HealthInformation.

CREDIT CARD INFORMATION: