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Marcy J. Gunn, Psy.D
Owner/Director of Child Psychology
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Jonathan M. Cleveland, Ph.D.
Director of Adult Psychology
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Chelsae Roby Pistello, Psy.D
Licensed Clinical Psychologist
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FORMS

Credit Card Authorization Form

CREDIT CARD AUTHORIZATION FORM

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

Credit Card Information

Card Type

I,

, authorize   Cordell Associates, LLC   to charge my credit card after each

therapy session. I understand that my information will be saved to file for future transactions on my account.

Thanks for submitting!

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