Credit Card Authorization

MICHELLE WAKELEY LICSW LLC 

dba AWAKEN MENTAL WELLNESS

726 E. Park Ave. #185

Fairmont, WV 26554

(304) 534-9321

By your signature of this form, you authorize charges to your credit card through Stripe via SimplePractice for services rendered. These charges will appear on your bank/credit card statement as PROFESSIONAL SERVICES. You have the right to request a paper copy of this document.

I authorize MICHELLE WAKELEY LICSW LLC dba AWAKEN MENTAL WELLNESS to charge my credit card through Stripe for therapy sessions, court-related activities, and any other services rendered on my behalf that are requested by me or required. I also agree that my credit card can be charged for any session that is not cancelled at least 48 hours prior to the scheduled session.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify MICHELLE WAKELEY LICSW LLC dba AWAKEN MENTAL WELLNESS in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form.

I acknowledge that credit card transactions could be linked to Protected Health Information.

Last updated: Feb 14, 2025

Client’s Name: ___________________________________  Client’s Date of Birth:  ___________

Client’s Signature: ________________________________  Today’s Date: _________________

IF THE CLIENT HAD ASSISTANCE REVIEWING AND COMPLETING THIS FORM, PLEASE INCLUDE:

Name of Person Assisting Client: __________________________________________________

Relationship to the Client: ________________________________________________________

Phone Number for Person Assisting Client: __________________________________________

Signature of Person Assisting Client: _______________________________________________