Credit Card Authorization | Sunny Devine

top of page

Patient Portal
Services
- Child Therapy Services
- Adult Therapy Services
Patient Forms
Etsy Shop
More

Use tab to navigate through the menu items.

Credit Card Authorization Documentation

Patient First Name*

Patient Last Name *

Name on Card*

Card Number*

Expiration Date*

Security Code*

Zip Code*

Authorization

I hereby give permission for Devine Counseling Services, LLC to keep my credit card information on file for payment of therapeutic services provided.

Full name*

Signature*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Connect on LinkedIn

©2025

bottom of page