Watanabe Psychological Services, LLC 2155501722 4. Credit / Debit Card Payment Consent Form Client name: (Card holder) Name on card if different than client: Card Type: Card Number: Security Code: Expiration Date: Billing Zip Code:

For your convenience, you may use a credit, debit, or HSA card to pay for your psychotherapy and any services related to psychotherapy. Please read each statement and sign to confirm your understanding and agreement to having your card charged for services rendered. I understand that payments are due at the end of each session and will be charged overnight following the completed session. I understand that I will not be notified prior to my credit card being charged. I understand that my card will be stored in a way that is HIPAA compliant; either in a locked file, a password protected and encrypted computer or an electronic health system. If the card holder is not the client, cardholder agrees that Collage Therapy Collective can charge this credit card in the manner described above for the client named above. I understand that should the situation arise, HSA cards may not be used to cover cancellation fees, and it is my responsibility to pay these with a personal card. I understand that if my payment fails, I will be sent an invoice. It is my responsibility to update my card on file should I need to change my payment method. I understand that I may request to be invoiced if I have a concern about being able to pay my session fee all at once, and understand that this will only be done in agreement with my therapist to delay payment if needed. 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 thirty days. Client Initials: Card holder Initials (If different than client): Date: