Credit Card Intake Form

Love and trust in the space between what is said and
what is heard can make all the difference.

Jim Maxwell, LPC, RYT
512-454-1850

This authorization form is necessary for online session payment and for late cancellation. I do not personally keep this card on file. Card information is submitted via an encrypted server. You may cancel this authorization at any time. Please complete all fields.

* Indicates required field

Cardholder Name as Shown on Card *

First

Last

Credit Card Number *

Expiration Date (mm/yy) *

CVV Code (3 digit code on back of card) *

The 5 Digit Zip Code of the Credit Card Billing Address *

Submit