Automatic Payment Authorization (Services)

Automatic Payment Authorization for Services

Provided by: Wellness Grove
Client Legal Name

First NameMiddle NameLast Name
Client Preferred Name
Client Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Last 4 of SS# for Client
Your Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your Email Address

Confirmation Emailexample@example.com

Here’s How Recurring Payments Work:

You authorize regularly scheduled charges to your checking/savings account or debit/credit card. You will be charged each services session that you are scheduled with Wellness Grove. Some of examples of services may include, but not limited to; clinical supervision, professional workshop and/or seminar. You will be charged for the total amount due on your part for that services session. You agree that no prior notification will be provided to you for each scheduled session. Additionally, any sessions that are missed and result in a no show or a valid cancellation late fee is assessed to your account, will also be charged without notification.

The fees associated with either a no call/no show and a late cancellation are as follows:
- No Call/No Show: full amount of the services session will be charged
- Late Cancellation: $60 cancellation fee will be charged.
A late cancellation is defined as cancelling a services session in 24 hours or less from the scheduled start date/time of the services session.
Method of Payment
Checking/Savings Account Details
Type of Bank Account
Name on Account
Bank Name
To provide an additional layer of protection, we request that you contact Wellness Grove in order to communicate your banking routing and account number at (330) 915-2907. If we do not hear from you prior to your appointment, we will reach out to obtain this information.

Please note that this authorization form is only valid for the banking routing number and account number that matches the name on the account and other banking details provided on this form.
Bank City/State

Street Address

Street Address Line 2

CityState

Zip Code
Debit/Credit Card Details
Card Type
Name as it appears on the card
To provide an additional layer of protection, we request that you contact Wellness Grove in order to communicate your card number, expiration, and security code at (330) 915-2907. If we do not hear from you prior to your appointment, we will reach out to obtain this information.

Please note that this authorization form is only valid for the card number, expiration, and security code that matches the card type and name as it appears on the card which has been provided on this form.

Acknowledge & Sign
I authorize Wellness Grove to charge/debit my account as indicated previously on this form at the beginning or after the end of each scheduled services session.

I understand that this authorization will remain in effect until I cancel in verbally or writing, and I agree to notify Wellness Grove verbally or in writing of any changes in my account information or termination of this authorization at least 5 days prior to the next services session. If the scheduled services session date falls on a weekend or holiday, I understand that the payment may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the services session begins or ends. In the case of an ACH transaction being rejected for Non-Sufficient Funds (NSF) I understand that Wellness Grove may at its discretion attempt to process the charge again within 30 days, and I agree to an additional $25 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this debit/credit card/bank account and will not dispute the scheduled transactions with my bank or credit card Company; provided the transactions correspond to the terms indicated in this authorization form.
Input Your Legal Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

Automatic Payment Authorization for Services

Here’s How Recurring Payments Work:

Checking/Savings Account Details

Debit/Credit Card Details

Acknowledge & Sign