3rd Party Recurring Payment Authorization

Thank you for paying for someone’s counseling sessions. That is a gift!
If you have any questions about this form, you can call our office at (970) 413-8998.

3rd Party Recurring Payment Authorization

  • You can define this in a number of ways: 1) # of sessions 2) Amount of money 3) Period of time 4) A certain event occurs 5) NA: The agreement will continue indefinitely
  • MM slash DD slash YYYY
  • Payment Method.

  • If choosing cash or check, we will still need a card on file in case of late cancellations, no-shows, or lack of payment. Thank you.
  • Thank you for caring and supporting this person.

    If we need anything else, Ann will reach out to you. Otherwise, you are done!
  • This field is for validation purposes and should be left unchanged.