Credit Card Authorization Form

Credit Card Authorization Form

We use Square to securely store your payment information and charge your card. HSA and FSA cards are now accepted.

Child's first and last name (or name of Adult receiving services):*

Name of person filling out form:*

Relationship to client:*

Your phone:*

Your Email:*

Cardholder Name (as shown on card):*

Billing street address:*

City:*

State:*

Zip code:*

Credit card number:*

Expiration date:*

Credit Card Security code:*

Authorization:

I hereby authorize Gold Speech, Inc. to charge the indicated credit card. I am aware of the company policy requiring cancellation by 7:00 a.m., if not sooner, the day of the scheduled session, to avoid the session charge. I am aware that I cannot receive reimbursement from my medical insurance for late cancellation fees of missed sessions. I agree that this is either a recurring or one-time charge that will be made, and I will not dispute it in the future. To terminate the recurring billing process, I must cancel in writing, preferably with 2 weeks notice.

I agree to the terms Type your name as your electronic signature:*

Optional comment:

Home practice strategies for carryover
Sibling, parent, grandparent participation
Collaboration with teachers, psychologists, physicians

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