Permission to Collect Payment

I authorize SpringSource Psychological Center, PLLC to charge my credit card for services and/or for any balance due that has not been paid 30 days after it is received.

I understand that if I miss the appointment or do not cancel 24-hours prior to the appointment, SpringSource Psychological Center, PLLC is authorized to charge my credit card the same amount as the missed appointment.

I have read and understand this form. I attest that the information below is true and accurate.


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