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Flowers

FORMS

First Visit Forms

Informed Consent - Jennifer Hall

TeleCounseling Informed Consent

Credit Card Authorization Agreement

Client Name

Guarantor Name

Effective Date of Agreement

I authorize Hall Counseling to charge the following credit/debit card for all counseling/psychological/educational services for the above mentioned client. This agreement may be revoked at any time by written request.

Name (as appears on card)

Card Number

Expiration Date

C V V

Billing Address

Zip Code

Guarantor Signature

Card won't be automatically charged. Hall Counseling will manually submit. Thanks for submitting!

OFFICE

1418 Heights Blvd
Houston, TX 77008

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HOURS

Hours vary for each therapist,

hallfamilycounseling@gmail.com

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