Credit Card on File Agreement

As an authorized signer on the credit card listed below, I give Psychological Counseling Services, Ltd. permission to utilize this credit card for all charges related to and including services rendered at PCS.

Your information is secure. Our website uses a Secure Sockets Layer (SSL) Encryption Certificate and all data is stored on a HIPPA Compliant server.


Please specify the client(s) whose charges will be billed to this card:

Client Name
Client Name
Client Name

Card Information

16-digit card number. Your information is secure.

We do not accept American Express, or Discover Card. 

Please format as 01/2017

3-digit security code

Billing Zip Code(required)
Is this a FSA/​HSA Credit card?

Additional Card required if FSA/HSA card

Insert and format text, links, and images here.

Confirm Full Name of Cardholder & Signer


I hereby state that I authorize payment of charges to Psychological Counseling Services for the clients listed above. This credit card authorization has been signed electronically and my signature may not be identical to my written signature.