Couples–Credit Card Agreement Please enable JavaScript in your browser to complete this form.Name *FirstLastPlease note: New clients are required to keep a valid credit card number on file. Please complete the following information and submit prior to your initial session.Credit card type: *Master CardVisaAMEXDiscoverName as shown on card: *Credit card number: *Expiration date of the card *CVV (3-digit security code) located on the back of the credit card: *Billing zip code associated with the card: *This card may be charged for: (check all that apply) *Regular session fees (at your request, as a convenience to you)Fees for cancellations with less than 24-hours notice (1/2 usual fee) Fee for uncanceled appointmentsAGREEMENT *Please check the box to agreeI have read and I understand the terms of providing my credit card information to Pitts Davis Counseling. I understand that my credit card may be charged for the reasons indicated above. Any questions I have about this practice have been answered.Signature *Clear SignatureDate *Submit