Name:

I hereby authorize Elizabeth Platé to charge for session cancellations under 48 hours *

Payment type: *

Unless prohibited by law, you agree not to cancel, revoke, charge back or dispute any previously entered charge on your credit card. If you do so, and it is later determined that the charge was properly authorized, you then agree to pay all out of pocket fees and costs incurred by my lawyer/ collection agency of as a result of improper cancellation, revocation, charge back, or dispute. Signature of Card Holder: *

Credit Card Information *

Billing address: *

Meet the Therapist

I hereby authorize Elizabeth Platé LCSW-R to charge the assessment/session fee or balances on my account *

Name: *

RELATIONSHIps...understanding, listening, supporting

Elizabeth A. PlatÉ L.C.S.W.R. PSYCHOTHERAPIST

P:516.702.3013 f:631.653.5774

Westhampton/quogue www.elizabethplate.org

(A scheduled appointment means that a time has been reserved for you in advance with your acceptance.) FULL 48 HOUR NOTICE must be given if you are unable to attend. Failure to give notice will result in a cancellation fee based on your session. *

Card holders name: *

The undersigned guarantees performance of the financial provisions of this agreement.: *

Phone number: *

Offering Teletherapy for your busy life!

Card holders date of birth:

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CLIENT CREDIT CARD PRE-AUTHORIZATION

In an effort to serve our clients and simplify your billing experience, credit cards and Paypal are accepted. Charge card information is filed with your confidential client information and kept secure. Accounts on file can be charged either automatically each month as a request from you, or as a back up payment in the event of a balance due and/ or for a cancellation fee.