Credit Authorization Form - Broward Center for Counseling

Please complete ALL fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until canceled.

Name(Required)

Client First Name Client Last Name

Type of Card(Required)

Credit Card Number(Required)

Credit Card Expiration Month(Required)

Credit Card Expiration Year(Required)

CVV Number(Required)

3 or 4 Digit Code (Back of Visa and Mastercard)

Card Type(Required)

There will be a 4% fee for Credit Card transactions

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I authorize "Broward Center for Counseling" (BCC) to charge my credit card for psychotherapy sessions. I understand that my information will be saved to file for future sessions on my account.

Signature(Required)

Date(Required)

CAPTCHA