Payment Form

CREDIT CARD AUTHORIZATION FORM

In order for Sahaya Therapy, LLC to accept and bill your credit card, please complete all fields in its entirety, sign, date and click on submit. All information submitted is strictly confidential and Sahaya Therapy, LLC adheres to the highest standards of account data protection.

First Name(Required)

Last Name(Required)

BILLING INFORMATION

As it appears on your credit card statement.

Street Address(Required)

State(Required)

City(Required)

Zip Code(Required)

CHECK THE APPROPIRATE BOX

One Time Use: I hereby authorize Sahaya Therapy, LLC to charge the indicated credit card the amount indicated below. This is a one-time charge authorization. I am not authorizing Sahaya Therapy, LLC to set up my account within a recurring billing system. I understand that if I want Sahaya Therapy, LLC to charge any balances to my credit card in the future, I will need to submit another authorization form at that time or choose the "Recurring Billing" option below.

Recurring Billing: I hereby authorize Sahaya Therapy, LLC to charge the indicated credit card on a periodic basis for the amount due on services provided to me by Sahaya Therapy, LLC including but not limited to session costs, copays, cancellation fees, etc. This recurring payment authorization shall remain in force until cancelled by me in writing or three (3) declined payment transactions

Choose payment authorization type.

Payment Method

Configuration Required: To use the PayPal Checkout field, please configure your PayPal Checkout Settings.

Credit Card

Configuration Required: To use the Stripe field, please configure your Stripe Settings.

Payment Form

CREDIT CARD AUTHORIZATION FORM

BILLING INFORMATION

Quick Links

Supports

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Payment Form

CREDIT CARD AUTHORIZATION FORM

BILLING INFORMATION

Quick Links

Supports

Information

EAP Pre-registration