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Shores of Hope, L.L.C.

Licensed Psychotherapist in Macomb County, Michigan

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Card Holder Signature and Agreement

Please complete the form below, or print and fill out the PDF Card Holder Agreement, and bring it to your first appointment.

Checkboxes *

I hereby authorize Shores of Hope, PLLC to charge my credit card for current and future psychotherapy services performed. I also authorize Shores of Hope, PLLC to charge my credit card for sessions missed or cancelled without the agreed upon 24-hour cancellation notice

Type of Card *

Name on Card *

C.C. Number *

Expiration Date *

CVC Code *

Billing Address *

City *

State *

Zip Code *

E-mail *

Name

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