AP Form | The Mental Haven

Debit/Credit Card Form

You're receiving this form because you have selected to have your card charged two days before your session. This will happen at the end of our day, and you will receive a receipt through email every time your card is charged for your session.

If you choose not to go this route, please do not complete the form! If you receive this form in error, please disregard.

Please know that your information will not be shared with anyone and will be password-protected, as your information has always been.

First name

Last name

Email (to send receipts)

Billing Address

I understand I will need to reply to the text messages or emails 48 hours before my session if I want to cancel or reschedule without any penalty. I understand if I cancel or reschedule late, I will be charged any fees I incur as policy states.

I agree to my card being charged by TMH two days prior to my session. I understand I will receive a receipt upon the charge. If my card declines, my card will be charged again the next morning for a second time. If my card declines again, I understand I will receive an email with a link and 3 hours to complete the payment. Not completing the payment equates to me being a no-show and my session being cancelled.

I understand my card information will not be shared with anyone and will be kept password-protected.

If I request a refund and it is granted by TMH, I understand I will be responsible for any fees incurred by TMH to conduct this transaction.

I understand I can complete this form and change my card information at any time.

Front of card

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Back of card

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Debit/Credit Card Form

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