Payment Authorization

Payments are due at the time of service. Billing occurs either biweekly or monthly according to treatment plan. Payment Invoices are provided during the first and third week of every month. Payments are discontinued upon formal written notice of service termination.

Client’s Name

First Name

Last Name

Credit/Debit Card Number

Expiration Date

Security Code

Billing Zip Code

Virtual Signature:

I have read and understand the above agreement and with my signature below, authorize Latitude Mental Health to charge my credit card accordingly