CLIENT PAYMENT
AUTHORIZATION FORM
The purpose of this form is to grant Embodied Wellness permission to charge your credit card for
recurring payments for your scheduled sessions. The information on this form will be entered and stored
securely through Quickbooks Online, which will then occlude your payment information details so that
your sensitive information is not accessible. This form will also be occluded once your payment
information has been transferred to Quickbooks Online. By signing this form, you agree to allow your
payment information and authorizing signature to be used in the manner described above.
I authorize Embodied Wellness LLC to utilize my ACH or debit/credit card information to charge therapy
session fees and other agreed upon services such as group or event fees, consultations/supervision session
fees, Akashic Record reading fees and/or late cancel/no show fees. Please refer to the stated cancellation
and general fees policies in the initial paperwork you received and signed upon engaging in the
therapeutic relationship. These policies can also be found on the website at embodiedwellness.org. Your
signature below indicates that you have read and agree to the stated cancellation policy and fee schedule,
which is subject to change with notification by Embodied Wellness.
Additional Terms & Conditions:
- This authorization form is valid until cancellation has been received in writing/email. At the time
of cancellation, your account will be charged for any outstanding fees, unless other arrangements
have been made with Embodied Wellness.
- My account will be regularly charged at the beginning of the week for any sessions and/or
additional fees incurred during the week prior (Monday - Sunday.) There may be some fluctuation
of processing time/day due to holidays, administrative schedules, etc.
- Sessions and fees will be charged in accordance with current cancellation policies and fee
schedules as stated on the website or verbally stated by Embodied Wellness.
- I agree to not dispute any charges with my bank or credit card company unless I have already
attempted to rectify the issue with Embodied Wellness.
- Any fees associated with returned or rejected payments will be the responsibility of me, the
Client.
- In the event that my payment information changes, I agree to notify Embodied Wellness in a
timely and proactive manner, as to not incur any additional fees from the financial institution
involved or delay payment to Embodied Wellness.
- To minimize fees associated with credit card p ayments, I understand that I can choose to provide
my bank account information for ACH payment and no additional fees will be applied to my
regular payment. If I choose to provide a credit card or debit card for regular payment, a 2%
processing fee will be added to my regular balance.
Client Name:
Email:
Billing Zip Code:
Phone:
Please go to the next page to provide payment details and sign this agreement.