Card Information | The Mental Haven

Card Information (Required Prior to First Session)

This form allows The Mental Haven (TMH) to have a card on file if you are a no-show for a session or want to reschedule/cancel within 48 hours of your session or do not pay your balance. You will be charged a $65 fee if you reschedule after 48 hours, but before 6 hours of your session. Any rescheduling within 6 hours of your session incurs an $85 fee. The no-show fee is $85. You incur this fee if you do not attend your session within the first 15 minutes. We will never share your card information with anyone outside the practice or its owners. Your card will only be charged manually if we are charging the fee or if you have asked us to. Your card will not be charged or used otherwise. If you decide to end your services with TMH, or your case is closed (meaning we have stopped hearing from you after three attempts of reaching out), we will delete your card information from our files. If you decide to come back to TMH, we will ask for this information again. Please note that if your card declines when attempting to collect the fee, your services will be placed on hold until we can retrieve it.

***Please let us know if you have any issues with the form!

First name

Last name

Phone

Is your address correct on your driver's license/id? If not, please provide us with your current address.

I understand that my card is only being put on file to be charged only if I am a no-show, or cancel/reschedule within the 48-hour mark of my session. I understand that my card will not be charged manually for any other reason that this or if I ask.

I understand that I will be charged a $85 fee if I am a no-show to my session, cancel, or reschedule after the 48-hour mark. I also understand the price of the fees can be changed at any time at the discretion of The Mental Haven.

I understand that I may not be able to meet with my therapist if TMH is unable to collect the fee from my card. I understand I will have to wait to see my therapist until the fee is collected if in a situation as such.

Please provide a copy of the front of your card.

Upload File

Please provide a picture of the back of your card.

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Card Information (Required Prior to First Session)

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